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UNITED STATES OF AMERICA. 



THE 



DIAGNOSIS AND TREATMENT 



OF 



DISEASES OE THE EAR 

/ BY 

OREN D. POMEROY, M.D. 

SURGEON TO THE MANHATTAN EYE AND EAR HOSPITAL ; OPHTHALMIC AND AURAL SURGEON 

TO THE N. Y. INFANT ASYLUM ; CONSULTING SURGEON TO THE PATERSON EYE 

AND EAR INFIRMARY ; MEMBER OF THE AMERICAN OPHTHALMOLOGICAL 

AND OTOLOGICAL SOCIETIES, ETC. " 



With one hundred illustrations 






fa 



SECOND EDITION BEVISED, WITH ADDITIONS. 




NEW YORK: 
D. APPLETON AND COMPANY, 

1, 3, and 5 BOND STREET. 

1886. 



V Xx 







Copyright, 1885, 

BY 

OREN D. POMEROY. 



r 
til 



PREFACE TO THE SECOND EDITION. 

As the first edition of this book has been disposed of, and a 
change of publishers brought about, an opportunity for revision 
and additions has been taken advantage of. 

The whole book has been carefully gone over, and many 
changes made. About thirty pages have been added, also a 
few woodcuts, while many of the old ones have been re- 
engraved, and it is hoped that the book will present a satisfactory 
appearance. 

The Author cannot but feel encouraged by the treatment 
the book has received from the press and the profession. No 
change has been made in the general scope of the work, as 
the Author intended to do what was at first done. 

OREN D. POMEROY. 

New York, Oct., 1885. 



PREFACE TO THE FIRST EDITION. 



One of the first things which the reader will notice in 
the perusal of this book is the absence of Anatomy and 
Physiology. I have occasionally mentioned an anatomi- 
cal or physiological point, where it has seemed essential 
to the understanding of the subject. Where it is desired 
to study the anatomy and physiology of the ear thoroughly, 
the books devoted to such subjects treat the matter more 
exhaustively than ordinary text-books on the diseases of the 
ear can possibly do. 

As my time for the preparation of this book has been 
limited, I have done what I could to produce an acceptable 
work for the use of the Practitioner, and it is hoped that 
some of the younger Aural Surgeons may find something 
in it to aid them in their practice. From the nature of 
things, a text-book cannot be exhaustive; neither would 
it be desired, if it were possible. 

The original illustrations in this book are from pen- 
drawings by Dr. J. O. Tansley, of New York, whose initials 
may be found appended to the cuts. 

I can only hope for the indulgent kindness of my friends 
in overlooking the defects, which may readily be found in 
this book. 

Oren D. Pomeroy. 

Lexington Avenue, near 38th St. 
New York, April, 1883. 



CONTENTS. 



INSTRUMENTS USED IN THE EXAMINATION OF THE EAR, 
WITH HINTS AS TO METHODS, MODES OF TESTING 
THE HEARING, AND THE APPEARANCES OF THE NOR- 
MAL DRUM MEMBRANE. 

Mirrors and Specula t 7 to 22 

Hints as to the Proper Mode of Examining the Ear 23 

The Eustachian Catheter and the Method of its Use 24 

The Faucial Eustachian Catheter 28 

Ths Use of the Tuning Fork in Diagnosis 32 

The Different Modes of Testing the Hearing '. 37 

The Appearances of the Normal Drum Membrane 41 

THE DISEASES OF THE AURICLE. 

Preliminary Observations 45 

Eczema of the Auricle 46 

Herpes Zoster Auricularis 49 

Erysipelas of the Auricle 51 

Horny Growths of the Auricle 52 

Intertrigo Auricularis 52 

Fibrous Tumors of the Auricle 53 

Haematoma Auris : Othsematoma 56 

Perichondritis Auriculae 59 

Injuries of the Auricle 73 

Abscesses of the Lobulus 75 

Congenital Malformations of the Auricle, and Other Portions of the 

Organ of Hearing 76 

DISEASES OF THE EXTERNAL AUDITORY CANAL. 

Foreign Bodies in the Meatus Auditorius Externus and Tympanic 

Cavity So 

Impacted Cerumen 86 

Desquamative Inflammation of the Meatus Auditorius Externus and 

Membrana Tympani 9S 



14 CONTENTS. 

Acute Circumscribed Inflammation of trie Meatus Auditorius Externus. 

— Furuncles of the Meatus 100 

Diffuse Inflammation of the Meatus Auditorius Externus 107 

Myringomycosis Aspergillina (Wreden) 115 

Exostosis and Hyperostosis of the Meatus Auditorius Externus 123 

INSTRUMENTS FOR THE EXAMINATION OF THE 

THROAT AND NARES 130 to 133 

Tongue Spatulae 131 

Rhinoscopic Mirrors 133 to 134 

McKenzie's Condenser 134 

Nasal Specula 135 to 136 

DISEASES OF THE MIDDLE EAR. 

Acute Catarrhal Inflammation of the Middle Ear 136 

Chronic Catarrhal Inflammation of the Middle Ear 157 

Acute Purulent Inflammation of the Middle Ear 226 

Chronic Purulent Inflammation of the Middle Ear 239 

Aural Polypi 269 

The Artificial Drum Membrane 275 

MASTOID AFFECTIONS. 

Periostitis of the Outer Surface of the Mastoid 278 

Primary Inflammation of the Mastoid and its Cells 282 

Inflammation of the Mastoid Cells 284 

UNCLASSIFIED DISEASES. 

Some Considerations Regarding Fatal Cases of Suppurative Otitis, with 

or without Mastoid Complications 307 

Malignant Disease In and About the Ear 316 

The Effects of Quinine on the Ear 331 

Affections of the Ear Influenced by or Dependent on Malaria and 

Defective Drainage 333 

Syphilitic Inflammation of the Middle Ear, the Labyrinth, and 

Acoustic Nerve 338 

Affections of the Ear Dependent on Hereditary Syphilis 347 

The Deafness of Boiler-Makers, Ship-Calkers, and Others who are 

Exposed to Similar Influences 355 

Labyrinth Diseases Dependent on Middle-Ear Affections 357 

Double Hearing, Paracusis Duplicata (Moos) 366 

Diseases of the Acousticus and Labyrinth Dependent on Affections of 

the Brain and its Meninges 369 

Deafness Dependent on Cerebro-Spinal Meningitis 373 



CONTENTS. 15 

Meniere's Disease 377 

Certain Affections of the Labyrinth and Tympanum Dependent on 

Traumatism 385 

Primary Acute Inflammation of the Membranous Labyrinth 390 

Deafness Dependent on Sclerosis of the Posterior Columns of the 

Spinal Cord '. . . 392 

Deafness from Sunstroke 394 

Deafness from Mental and Nervous Exhaustion 395 

Deafness from Mumps 395 

Deafness Dependent on Gestation and Parturition 399 

Diseases of the ear Dependent on Typhus and Typhoid Fevers 401 

INSTRUMENTS FOR AIDING THE HEARING. 

Ear Trumpets 403 

The Audiphone 406 

Japanese Fan 408 



DISEASES OF THE EAR, 



INSTRUMENTS USED IN THE EXAMINATION OF 
THE EAR. 



The first step in the study of diseases of the ear is its 
proper examination. The auricle and the outer portion of 




Fig. i. 
Pomeroy's forehead mirror. 

the meatus externus require no apparatus for their exami- 
nation; the deeper parts of the meatus and the mem- 



I 8 DISEASES OF THE EAR. 

brana tympani, however, require special appliances for 



Fig. 2. 

Dr. Smallwood's forehead mirror. 



examination, and some directions as to the best meth- 
ods. In the first place a concave mirror of about sever. 



FOREHEAD MIRROR. 



19 



inches focus and three to three and a half inches in di- 
ameter is needed. The one here figured, and known as 
Pomeroy's (Fig. 1.), I am in the habit of using, although 
there are many others which fully answer the purpose. 
tig. 2, known as Dr. Smallwood's mirror, with double 
ball-and-socket joints, is a very admirable instrument. In 




Fig 3. 

Wilde's speculum. 




Fig. 5. 
Gruber's speculum. 




Fig. 4. 

Toynbee's speculum. 



all the mirrors which fairly meet the indications, an 
appliance for fastening them to the forehead should be 
used. This requires a ball attached to its back, to which a 
clamp is applied, so as to produce a universal joint. The 
author's mirror is attached to the head by an inelastic 
band of silk. A handle may be attached to the mirror 



20 DISEASES OF THE EAR. 

when it is not found necessary to use it against the fore- 
head; but this is hardly necessary, it being quite easy to 
hold the mirror by the forehead piece, and the handle 
maybe dispensed with. The next requirement is a spec- 
ulum. Three kinds may be recommended: Wilde's, Toyn- 
bee's, and Gruber's (Figs. 3, 4, and 5). As the meatus 
externally is oval, Gruber has thought fit to make his spec- 
ulum oval to more readily adjust itself to the shape of the 
canal. I am not in the habit of using Gruber's speculum, 
for the reason that it is oval; as I insert the speculum with 
a twirling movement, this shape would be faulty. Again, the 
meatus being externally cartilaginous, is sufficiently mobile 
to adjust itself to a circular speculum without difficulty. 
The Toynbee speculum is funnel-shaped: that is, the outer 
surface represents a concave line extending from tip to rim, 
and is very easily inserted, and may be moved from side to 
side, and be easily directed to any part of the canal 
or membrane we may desire to inspect. It is, however, 
obviously a poor speculum for operations. The Gruber 
speculum bulges at the outer portion, which presents a roomy 
space to operate in. The Wilde speculum manifestly com- 
bines the characteristics to some extent of both the previous 
varieties. All the forms of bivalve specula I am inclined to 
discard, except in a few instances when operating. Kramer's 
(Fig. 6) or Speir's (Fig. 7) are as good as any. Miliken's 
Self-retaining Speculum (Fig. 8) will sometimes be found 
useful. For purposes of magnifying, a variety of otoscopes 
have been devised, such as Hinton's (Fig. 9), or Brunton's 
(Fig. 10), or Hassenstein's (Fig. 11), or Simrock's (Fig. 12). 
I am not, however, in favor of these instruments ordina- 
rily. The Hinton and Brunton instruments are useful for 
demonstrating the appearances of the membrana, but this 
mode of studying the ear is at best a poor one; the student 
should overcome the difficulties of making an examination 
without these aids. Too much assistance is evidently un- 
profitable. The forehead mirror being in position, I place 
a + -J- or + \ lens against the opening of the speculum, 
somewhat obliquely, so as not to be annoyed by the 
reflections, and then by a to-and-fro movement focus the 
parts perfectly. Moreover, changing the position of the 
glass in this manner aids in determining the perspective. 
Another method is to place a clip behind the mirror, and 
insert a lens which will sufficiently magnify. A -f T V or 
+ ffo will sufficiently enlarge the image. It is also con- 



EAR SPECULA. 



21 




Fig. 6. 
Kramer's bivalve spec- 
ulum. 



Fie. 7 . 
Speir's bivalve speculum. 




Fig. 8. 

Miliken's self retain- 
ing speculum. 





Fig. 9. 
Hinton's speculum. 



Fig. 10. 
Brunton's speculum. 



22 



DISEASES OF THE EAR. 



venient if the surgeon happens to be far-sighted or pres- 
byopic. 

The kind of illumination to be selected is a very im- 
portant matter. I am firmly of the opinion that daylight 
when at its best is the most satisfactory means of illumina- 
tion. I would define this condition to be a cloudy day with 
very thin white clouds; a room admitting light from one win- 
dow, or, what would be better, from a single pane of glass. 
The argument then turns on the frequency with which we 
obtain this condition. The direct sunlight is manifestly 
bad. The light from the blue sky is of faint illuminating 
power. The light reflected from a white house is good, 






Fig. ii. 
Hassenstein's speculum. 



Fig. 12 
Simrock's speculur 



but it is bad from a house of any other color. On the other 
hand, some form of gas, coal oil, or candle-light is always at 
our service, and is adequate to a proper examination of the 
ear. The only objection to this kind of illumination is the 
reddish-yellow color of the light, which gives to the mem- 
brana tympani a slightly changed appearance; that is, a red- 
dened membrane will look a litte too red by gas-light. 
Even this could be obviated by placing a blue chimney 
upon the lamp. The advantage of the artificial light is, 
that it is always of the same quality, and if the normal 



MODE OF EXAMINING THE EAR. 23 

membrane is studied by gas-light, there is no difficulty in 
detecting any deviation resulting from disease. 



HINTS AS TO THE PROPER MODE OF EXAMINING THE EAR. 

If daylight only is used, the mirror requires a focal 
length of about ten or twelve inches. It is not difficult, 
to understand how a lamp placed near the ear, and 
giving off divergent rays, would require a mirror of a 
shorter focus; hence the recommendation of a seven-inch 
mirror in the second instance. In ordinary examination of 
the ear, the patient may be placed opposite a window ; if 
daylight be used, the rays of light should be caught on the 
mirror, and thrown focussed upon the membrana. 

If, however, the patient is placed at some distance from 
the window, more light will fall upon the mirror, as 
there will be added to this light, that which has been re- 
flected from the side of the room corresponding to the win- 
dow; moreover, being in the darker part of the room, some 
benefit will result from the contrast between the somewhat 
darkened part where the patient is sitting and the quite 
bright reflex from the mirror. Again, the much diminished 
size of the reflected image of the window from the distance, 
will appear to sharpen and brighten it. Unless operating, 
I would generally recommend to hold the mirror in the 
hand, and not place it on the forehead. As the meatus ex- 
ternus has practically two curves — that is, the inferior wall 
has a convexity looking upward, and the anterior wall a 
convexity looking backward — it is evident that if the canal 
were straightened a better view of the drum membrane could 
be obtained. This is possible, as the outer portion of the 
canal is cartilaginous and somewhat movable. It is accom- 
plished in this manner: Grasp the auricle by its upper part, 
between the first two fingers; then draw it upward, back- 
ward, and outward, when the membrana is well exposed to 
view. The outward movement of the auricle is indicated 
to be made when the canal is somewhat collapsed, as in 
certain inflammatory affections. In elderly persons also 
it may be somewhat collapsed from flaccidity of its soft 
parts. 

The speculum may now be introduced, first moistened in 
water, by a gently screwing motion, being careful not to 
reach beyond the middle of the canal, for when it impinges 
2 



24 DISEASES OF THE EAR. 

against the osseous portion a feeling of discomfort or even 
pain is experienced. When pushed far enough inward, it 
is held in position by the thumb and forefinger if it be the 
right ear, and the thumb and third finger if the left. The 
inner portion of the canal is examined in detail by inclining 
the speculum first to one side then to the other, then up, 
then down. A Toynbee speculum will obviously do better 
for this purpose. 

THE EUSTACHIAN CATHETER AND THE METHOD OF ITS USE. 

Ordinarily, three sizes of the catheter may be selected, 
with the occasional addition of a fourth smaller size. The 
largest-sized catheter which will readily enter the nostril 
should be chosen. Catheters may be made of pure silver, 
which are very readily bent to any desired shape. German 
silver is also used, as well as other and less expensive 
metals, which are afterwards plated with silver or nickel. 
One advantage of the metallic catheter is, that from its 
greater weight it more readily falls into position when in- 
troduced. The hard rubber catheter is inexpensive, light, 
does not become corroded or soiled when remedial agents 
are sent through it. It is readily bent to any shape after 
immersing in hot water, or exposing it for a few seconds 
over the flame of a lamp or gas-jet. However heated, the 
catheter, when bent, must be held in this form until cool, in 
order that the new shape may be permanently maintained. 
If it be immersed in cold water this may be accomplished 
immediately. I usualty prefer catheters of this material for 
the reasons above stated. It is not necessary to have a bul- 
bous tip to the catheter, as has been recommended by some. 
The curvature of the instrument must be sufficient to fill 
the meatus when introduced into the Eustachian tube [that is, 
the convex side of the catheter should touch the wall of the 
nostril opposite the mouth of the Eustachian tube], and 
may be sharp in some instances and gradual in others. 
This is determined by the readiness with which it is in- 
troduced ; sometimes entering the Eustachian tube better 
with a short curve, and in other instances with a more 
gradual one. No two patients are likely to require a 
catheter of exactly the same curve. A ring or screw 
at the larger end of the catheter indicates the direction 
which the nozzle takes when it enters the Eustachian 
tube. (The addition of the screw is a device of Dr. 
Roosa.) The patient may be seated in a chair having a 



MODE OF INTRODUCING THE CATHETER. 2$ 

high back to lean his head against when having the cathe- 
ter introduced, or this may be dispensed with. The head 
is thrown back, the tip of the nostril pushed slightly up- 
ward, so as to expose the inferior meatus, and the catheter, 
previously dipped into water, is passed with the ring or 
guide downward along the floor of the inferior meatus 
until it reaches the posterior wall of the pharynx. It is 
then withdrawn, in some instances a little more and in others 
a little less than half an inch, then turned so that the 
ring points towards the ear corresponding to the tube we 
wish to enter; then, by a variety of manipulations, seek to 
adjust the catheter to the mouth of the tube. To this end 
the catheter may be moved upward, downward, or toward 
either side. When it is fixed in the Eustachian tube the 
sensation imparted to the hand of the operator gives 
assurance as to this* fact. This final position, the result 
of a quarter revolution of the instrument, is not readily 
attained, for the bend of the catheter needs to be so great 
as to make it a little difficult to accomplish this requisite 
turn. If the surgeon is not particular about fitting the 
catheter well into the tube, but is only desirous to come 
near to its aperture without passing within, — which often 
does nearly as well, — a bend so moderate that the instru- 
ment can be turned in the nostril with perfect ease may be 
used. 

When the catheter is in position, the patient can talk, 
whistle, etc., without danger of dislodging it. There are 
many cases where, from malformation of the nares, it is 
impossible to introduce the catheter by this method. It 
will be proper in such exceptional cases to pass the beak 
of the catheter in, pointing upward or sometimes toward 
one side or the other — that is, in any direction in which we 
may succeed in introducing it. Sometimes it will be ad- 
visable not to pass the instrument further than the fossa of 
the Eustachian tube, and enter it at once — in other words, 
use any manipulation whatever that succeeds in introducing 
the catheter. Occasionally a very small catheter may be 
introduced where a moderate-sized one would fail to pass. 
Where one nostril will not allow a catheter to be intro- 
duced, the other may. Taking advantage of this circum- 
stance, catheters of extra length of curve have been 
constructed, so as to enter the tube through the opposite 
nostril. This does not allow the beak of the catheter to 
enter the mouth of the tube, but to impinge upon its an- 




Fig. 13. 

At the right may be seen Noyes's double curved Eustachian catheter, and to the left 

the ordinary Eustachian catheter. 



NOYES'S MODIFICATION OF THE CATHETER. 2J 

terior wall. It is true that the tympanum may be inflated 
by this form of the catheter, but not as well as when intro- 
duced in the ordinary manner. To correct this faulty 
adaptation of the catheter to the mouth of the tube, Dr. 
Noyes of New York has suggested, in the Tr. Am. Otol. 
Society, 1870, a catheter with a double curve of extra 
length. The cut Fig. 13 will exhibit the manner in which the 
second curve is made to point exactly in the direction of 
the axis of the Eustachian tube, and enables it to be in- 
serted properly. No particular directions are necessary 
for introducing this form of the catheter except to keep the 
beak as near to the nasal septum and floor of the inferior 
meatus as possible, until the neighborhood of the Eusta- 
chian tube is reached, when the same rules given for the 
ordinary introduction of the catheter will suffice. I might 
perhaps state in this connection that a very satisfactory 
way out of this difficulty in entering the nostrils is found in 
the use of the faucial Eustachian catheter. The Eustachian 
catheter may be used without a holder. For some pur- 
poses, however, as, for instance, in injecting steam into the 
middle ear or in any other prolonged use of the catheter, a 
holder will certainly be convenient if not indispensable. 
My own catheter holder (Fig. 44) will answer this pur- 
pose. A description is hardly necessary ; a pivot in the 
forehead piece allows the holder to swing first to one nos- 
tril, then to the other, besides allowing the clamp which 
holds the catheter to slide in a vertical direction. Before 
fastening the catheter, this part of the instrument is moved 
above its level, and when applied is slipped down, the blades 
of the clamp being placed on either side of the catheter. 
These are made to grasp the catheter by means of a small 
thumb-screw. When inflating the ear by means of the 
catheter, the surgeon's mouth may be applied to a rubber 
tube attached to the catheter by means of a tip which 
readily adjusts itself to the end of the catheter without 
pushing or in the least degree changing its position. 
Better than this, however, is the Politzer air-bag, with the 
tip made adjustable to the catheter. The bag may be used 
with an aperture, rather than an expensive valve, liable to 
get out of order. During an attempt at inflation the patient 
maybe directed to swallow, or resort to the various manoeu- 
vres recommended under the head of Politzer's inflation. 
Great care needs to be taken not to lacerate the mucous lin- 
ing of the pharynx by the catheter, for on attempting to 



28 DISEASES OF THE EAR. 

inflate subsequently, a very annoying and possibly danger* 
ous emphysema may result. I have reason to believe that 
I once lacerated the mucous membrane in attempting to 
introduce a catheter, and subsequently on inflating the ear 
I produced emphysema of the cellular tissue surrounding 
the posterior pharyngeal space, especially that of the velum 
pendulum palati. The patient could not breathe well for 
some minutes, and he was fearful that suffocation might 
result. I made several minute punctures into the uvula, 
which was acting as a valve to obstruct inspiration, with 
almost immediate relief. I previously, however, had 
directed him to breathe through the nose, so that the 
velum might fall into a more natural position, and cause 
less obstruction to the respiration. The two cases of death 
from the introduction of the catheter, published many 
years since, have done much to cause timidity in catheter- 
ization. I do not draw any important conclusion from 
these cases, however, nor do I believe that life is jeopar- 
dized by the use of the Eustachian catheter. 



THE FAUCIAL EUSTACHIAN CATHETER, AND THE METHOD OF 

ITS USE. 

In 1872 I published an account in the Transactions of 
the American Otological Society of an instrument for inflat- 
ing the middle ear, and making applications to the mouth 
of the Eustachian tube by way of the throat. I had pre- 
viously been using the Eustachian catheter, selecting in- 
struments with a moderate curvature so as to be more 
readily introduced. This was attached to the air-bag by 
means of a rubber tube about twelve inches in length. Sub- 
sequently I made a right-angled bend in the catheter, passed 
it behind the velum, and succeeded in readily inflating the 
tympani by this means, the rubber tube and bag being used 
as in the first instance. I found that with a good-sized 
catheter, having a large calibre, I could force air enough 
behind the velum to inflate both ears simultaneously, and 
often excessively. Afterwards I used a catheter with a 
smaller aperture so as to obviate that difficulty. From that 
instrument to the present one was but a step. This instru- 
ment (Fig. 14, reduced nearly one half) is made of hard rub- 
ber, seven and a half inches in length ; breadth at its* larger 
extremity one-fourth of an inch, gradually tapering to its 



pomeroy's faucial eustachian catheter. 29 

beak, which is a little more than one eighth of an inch in 
thickness. At the larger extremity is a tip for the adjust- 
ment of the rubber tube; beyond this, at the distance of 
about an inch and a half, is a guide placed perpendicularly 
to the shaft of the instrument, and pointing in an opposite di- 
rection to the bent extremity of the tube. This will indicate 
the direction of the beak of the instrument when placed be- 
hind the velum, and consequently out of sight. The bent 
portion of the tube is one inch and three sixteenths in 
length, and forms an angle of about 8o° with the shaft of 
the instrument. Within a line from the extremity of the 
tube is an aperture the size of a No. 1 Bowman probe for 
the passage of air and fluids for injecting the tympani. 




Fig. 14. — Pomeroy's Faucial Eustachian Catheter. 

This is placed at an angle of about 65 to the bent portion 
of the tube. It will be seen that when the catheter is prop- 
erly introduced, the aperture will point in the direction of 
the axis of the Eustachian tube. The instrument is not 
properly a catheter, for the beak does not enter the Eusta- 
chian tube, but simply comes in contact by its small aper- 
ture with the faucial opening of the tube. 

It is introduced in the following manner: The instrument, 
with its perforated rubber bag and rubber tube, is caught 
by its larger extremity (but not by the guide), held lightly 
in the left hand, while the right hand holds the rubber bag, 
with the thumb on the aperture. No tongue depressor is 
ordinarily necessary. The instrument is passed in with the 
bent extremity pointing downward, as it must pass over the 



30 DISEASES OF THE EAR. 

tongue, which may rise up considerably, and present a 
convex surface. No effort should ordinarily be used to de- 
press the tongue, being careful, however, not to excite it to 
resistance by rough or slow manipulations in the introduc- 
tion of the instrument. In view of the fact that the patient 
sometimes inclines to withdraw his head when the catheter 
is about to be introduced, it is well to catch the lower jaw 
with one of the fingers of the right hand — which may still 
hold the bag — thereby fixing the patient's head. If the pa- 
tient's head is placed against a solid support, he is likely to 
cause annoyance to the operator by a sudden lateral move- 
ment to escape the instrument, which would be more embar- 
rassing than if the head were left free. The catheter is then 
turned quickly upward, and insinuated behind the velum. 
During this manoeuvre the patient may be requested to pro- 
nounce the letter a, prolonging the sound. If the velum is 
thrown backward against the posterior wall of the pharynx, 
the patient may be directed to breathe through the nostrils, 
when it is likely to fall into a natural position, giving a suf- 
ficient space for the passage of the instrument behind it. If 
the right tube is to be inflated, turn the beak of the instru- 
ment to the right of the throat so that it shall stand at an 
angle of about 40 ; draw the instrument gently forward and 
inflate. If the velum is thrown backward in a spasm, the 
catheter will require to be drawn forward rather forcibly, 
but this condition of things is, if possible, to be avoided. 
In order to inflate the left ear, the catheter may be intro- 
duced as described for the right, except that the curve of 
the instrument must point to the left, 90 from the position 
it previously occupied. It is a good manoeuvre to pass the 
instrument in at the right side and turn it to the left, when 
the latter is to be inflated. If the velum resists this ex- 
cursion, which it frequently does, then the patient may be 
directed to breathe through the nose; and if that fails to 
place the velum in position, the difficulty is overcome by 
suddenly moving the handle of the catheter up and down 
during the effort to turn it to the opposite side. By this 
procedure the end of the instrument is, so to speak, un- 
hooked from the spasmodic velum, and allowed to move 
freely. 

If it is needful only to inflate, this maybe done for both 
ears, without removing the catheter from the throat. This 
may be accomplished in four or five seconds if the surgeon 
is required to work rapidly and has a reasonable amount 



POMEROY S FAUCIAL EUSTACHIAN CATHETER. 3 1 

of dexterity. For a number of years some of the members 
of the surgical staff at the Manhattan Eye and Ear Hospital 
have turned over patients to me where they had failed to 
inflate the tympani, and I have so far not failed to inflate 
in using this instrument. Of course no real stricture could 
have existed in any of these cases. 

I can inflate the tympanic cavities more rapidly with this 
instrument than by Politzer's method or any of its modifica- 
tions. The delay with the last-named methods arises from 
the fact that the patients will not always swallow or phonate 
or respire so as to make the operation successful, until con- 
siderable teaching has been expended on them, which of 
course consumes time. If the patient swallows exactly 
when an attempt is made to inflate, the operation is quickly 
done, but he does not often do this. 

When it is desired to make an application to the mouths of 
the Eustachian tubes, my practice is to do it as follows: A 
dropper is used, by means of which a fractional part of a 
drop, or several drops, as may be required, is deposited on 
any non-absorbent surface. With the air-bag compressed, 
and the thumb on the aperture, the small extremity of the 
catheter at the opening is laid on the drop of fluid previous- 
ly deposited, and the air-bag is then allowed to fill; the fluid 
is drawn within the catheter, and it is ready for introduc- 
tion. If rapid work is desired, drops may be deposited in 
several places, to be ready for use. In applying the rem- 
edial agent, it is well not to force it in too strongly, as it 
may enter the tympanum, when the object is only to inject 
the Eustachian tube for a short distance, or even to apply 
it to the mouth of the tube. 

I have never had any serious accident from injecting the 
tympanum by this method, but some years since Dr. Weir, 
of New York, injected the tympanum by means of this in- 
strument, and excited an acute otitis media. If the fluid 
is sent with some little force a coarse spray is produced, 
which medicates a considerable portion of the side of the 
pharynx. If the application needs to be made with con- 
siderable exactness, I am in the habit of using only a small 
quantity of the agent. While testing the instrument, some 
years since, I was in the habit of employing a very small 
quantity of a saturated solution of silver nitrate, and I 
usually succeeded in making a minute white spot of cau- 
terized mucous membrane in the fossa of the Eustachian 
tube. Ordinarily I use one or two drops of a forty to 



32 DISEASES OF THE EAR. 

eighty grain solution of the nitrate. I have never receded 
from the ground I took years since, that in many cases of 
chronic catarrh of the tube no benefit resulted until a strong 
solution was used. I have within a week had a similar ex- 
perience. It has been urged that this instrument is exceed- 
ingly difficult to use properly. Personally, I am unable to 
judge; I have used it so much that any difficulties in the 
way of its employment may have unconsciously disap- 
peared. I cannot say that I have succeeded in teaching 
pupils to become as expert with it as I could have wished. 
I can, however, assert that I constantly use it, and in prefer- 
ence to other methods. In my hands this instrument is 
not as unpleasant to the patient as the Eustachian catheter, 
and I have latterly used that instrument much less fre- 
quently than formerly. In the case of children, the bend 
of the instrument may be about three fourths of an inch in 
length. As the instrument is made of hard rubber, it may 
be bent in any manner desired by heating it in boiling 
water, or placing it over the flame of a lamp, being careful 
not to burn the rubber. 



THE USE OF THE TUNING-FORK IN DIAGNOSIS. 

The tuning-fork is mainly used in differentiating between 
middle ear and labyrinth disease. Many varieties of the 
instrument are used, and the number of facts connected 
with the subject is so great that it would be foreign to the 
purpose of this book to go into detail. The subject will, 
however, be sufficiently developed, it is hoped, to be made 
available in ordinary practice. The kind of fork generally 
used is the one known as Politzer's, and is a " middle C " of 
512 vibrations per second. It is of large size, being 8 
inches in length, the prongs -J of an inch in width and 
-^ of an inch in thickness. It gives a powerful resonance, 
which is quite necessary in many cases of obtunded sensi- 
bility of the nerve. Clamps may be used, which prevent 
the harsh metallic sound of the over-tone; this is a fourth 
above the ground tone of the instrument. They also add 
greatly to the power of the undulations. By successively 
moving the clamps from the extremity of the instrument 
to the opposite end, the pitch becomes about twelve tones 
higher; any intermediate tones are produced by fixing 
the clamps in the proper position. This is of great ad- 



THE TUNING FORK. 33 

vantage, and makes a number of forks of different pitch 
less necessary. It will often be found that some of the fibres 
of Corti are destroyed, or at least are not active, when the 
fork vibrating in unison with such fibres will not be heard; 
hence the desirability of tuning-forks of different pitch. 
Many aural surgeons, however, of large practice use the 
tuning-fork without clamps. Dr. Blake, of Boston, has 
devised a hammer, one face of which is tipped with rubber. 
It is attached to the base of the fork by an elastic wire 
handle, which moves up and down through its point of at- 
tachment (Fig. 15). By drawing the hammer away a cer- 
tain distance each time a blow is given, great uniformity of 
resonance is obtained. It is possible, however, to secure a 
sufficiently uniform blow by striking the fork on the knee 
while the leg is flexed upon the thigh, or even extending 
the palm of the hand and striking upon its fleshy part. It 



Fig. 15.— Blake's Tuning Fork. 

is unnecessary to enlarge here on the desirability of great 
simplicity in instrumentation. The fork may be applied 
by its base to the front teeth, the forehead, temples, vertex, 
mastoid processes, and also held with the forked part near 
the ear. In the normal ear, the tuning-fork, when placed 
on the central incisors, is heard equally well in both ears ; 
the same is true if placed on the vertex or on the centre of 
the forehead. If placed on the mastoid process, it is heard 
better in the ear of the same side. If the patient has his 
tympani inflated with air the tuning-fork is not as well 
heard. Urbantschitsch states in his work on the ear that 
in some elderly people with normal hearing, the bone con- 
duction is defective [Politzer]. It is heard longer when 
placed near the meatus than by bone conduction; that is, 
when placed on the teeth, etc. This is best tested by hold- 
ing the fork on the teeth until no longer heard, when »it 
will be distinctly audible placed near tliG meatus. This 
is explained by the fact that the most natural hearing is 
through the air, by means of the vibratory mechanism of the 



34 DISEASES OF THE EAR. 

tympanum. E. H. Weber has discovered that if the meatus 
is stopped by the finger, or covered by the hand even, that 
the tuning-fork is heard better, as well as longer, in that 
ear. If the finger is pressed too far into the ear, however, 
it spoils the test; this latter observation has been made by 
Dr. J. A. Andrews, and has been verified by myself. Many 
explanations are given for this improved hearing when the 
meatus is closed, but the one given by Politzer and Mach 
seems the most satisfactory, namely, by stopping the ear the 
sound waves are hindered from their passage outward to the 
open air, and also are reflected inward, so that the nerve 
receives an augmented impression. This test requires to 
be made with the greatest care to prevent deception. If 
the tuning-fork is placed on the vertex, or in the centre of 
the forehead, or upon the central incisor teeth, and the pa- 
tient, with closed eyes, states by a fall of the hand the pre- 
cise moment at which it is not heard in either ear, and the 
hands fall simultaneously, we shall be quite sure that bone 
conduction is equally good in each ear. This test may be 
made with both ears closed. Naturally this would prove 
that bone conduction was the same in each, and it would 
be left for the voice or watch to test whether the hearing 
was perfect. 

Where there is some defect in the hearing, dependent on 
disease located in the middle or external ear, the tuning- 
fork placed by its base upon the teeth, or on any of the 
central portions of the skull, will be heard better in the 
diseased ear. If placed in the air, near the ear, it may not 
be heard as well (aerial conduction) as in the previous po- 
sition (bone conduction); but if the disease in the middle 
and external ear is not excessive, it probably will be heard 
somewhat better by aerial than by bone conduction. 

It is a better plan for the patient to signify the compara- 
tive length of time he hears the tuning-fork in each ear, it 
being more exact than to ask if he hears it better in one 
ear than in the other. It has been found in doubtful cases 
that if the fork is laid a little to one side of the median 
line, it assists to confirm a diagnosis. For instance, the pa- 
tient thinks he hears the fork better in the right ear, and it is 
then moved to the left side a little ; if he still hears it 
as well in the right ear, or even hears it equally well in both 
ears, then there is no question of his hearing it better in the 
right. If the suspected ear is closed, and there is little 
increase in the length of time the tuning fork is heard, 



THE TUNING FORK. 35 

evidence grows stronger of middle ear disease. When 
both ears are simultaneously closed, and the nerves are 
active, there ought to be very little difference in the length 
of time the fork is heard, unless we except a condition here- 
after to be explained as intermittent bone conduction. 

As to the mode in which the tuning-fork vibrations 
through the bones reach the nerve. There is no question 
but that sonorous impressions may be carried direct from 
the skull to the labyrinth. This seems to be proven by a 
case reported by Lucae in the Arch. f. Ohrenh., xvi., p. 88, 
and alluded to by Knapp in the TV. Am. Otol. Soc., 1880, 
p. 408, in which a case of congenital absence of the exter- 
nal and middle ear, but with a normal labyrinth, had good 
bone conduction on that side, but considerably better on 
the other side, which was normal. 

A much more important portion of the vibrations, how- 
ever, reach the nerve by means of the apparatus of the 
middle ear. A better way to state the idea, perhaps, would 
be to say that the membrana and ossicula are much more 
readily thrown into vibrations than the immovable petrous 
bone surrounding the nerve. Other evidences of the agency 
of the middle ear mechanism in carrying undulations to the 
labyrinth will appear in the part of this article devoted to 
intermittent bone conduction. 

When the deafness depends on disease of the parts be- 
yond the external and middle ear, the tuning-fork is heard 
badly or not at all in the deaf ear, when placed at any of 
the central positions we have before indicated. If it is a 
case in which there is little difference in the hearing of 
either ear, the manoeuvre previously referred to — moving 
the fork beyond the middle line — will aid us. If there is 
any hearing in the suspected ear it will be increased by 
stopping the meatus, although the increase may be very 
slight indeed. This is on the principle that stopping the 
ear adds to the number of vibrations falling upon the 
nerve, and consequently increases the hearing; if there is 
no hearing, there can, of course, be no increase by closing 
the meatus. If there is hearing by bone conduction, then 
there will be better hearing when the fork is placed near 
the meatus, as in middle-ear disease it may be heard worse 
under the same conditions. The explanation of this has 
already been given, and may here be repeated in this state- 
ment: if the middle ear is normal, the tuning-fork is best 
heard near the meatus; but if it be diseased, it may be best 



36 DISEASES OF THE EAR. 

heard by bone conduction. If both ears are stopped, the 
tuning-fork will probably be heard better in the good 
ear if it be a case of nervous deafness. Then, in general 
terms, the tuning-fork will be heard by bone conduction 
better in the bad ear in middle-ear disease, and worse in 
the bad ear in labyrinth disease. In many cases of middle- 
ear trouble, combined with labyrinth disease, the diagnosis 
will be very difficult indeed, and all the rules laid down 
must be applied, which will require great ingenuity and 
judgment on the part of the surgeon. The subject is still 
further complicated by recent developments pointing to 
what has been called intermittent bone conduction. This 
has been studied by Blirkner in the A. f. O., xiv., 96, and by 
Dr. J. A. Andrews in the New York Medical Journal and Ob- 
stetric Review for February, 1882, and by some others. The 
main points seem to be as follows: 

1. A patient with catarrhal otitis, obstruction of the tube 
and collapsed membrana, with defective aerial conduction, 
may have also bad bone conduction, but on inflating the 
tympanum and restoring the position of the membrana to 
the normal, or at least a bettered one, which probably im- 
proves the aerial conduction, also improves the bone con- 
duction, which may indeed be better in this ear than the 
normal fellow, in accordance with the rule. This condition 
may return to the former state if the tube becomes again 
closed with collapse of the membrana. 

2. Pressure upon the round or oval windows, from fluid 
in the tympanum, masses of inspissated secretion, as dried 
flakes of mucus, pus, blood-clots, etc., interfere with both 
bone and aerial conduction, but on the removal of these 
restoration of both forms of conduction may result. 

3. Excessive hyperemia of the tympanum may interfere 
with both bone and aerial conduction, which may return 
on the subsidence of the congestion. 

4. Anything whatever that interferes with the free vibra- 
tion of the membrana tympani, the membrane of the round 
window, the ossicula, including the impacted base of the 
stapes in the oval window, interferes with bone conduction, 
which may be improved by the removal of the hindrance to 
free vibration of these parts. 

In connection with this subject of intermittent bone con- 
duction, it may be interesting to discuss briefly the condi- 
tion of the organ of hearing, where its function has been 
interrupted by some disturbance situated in the tympa- 



THE TUNING FORK. 37 

num — as to whether the lowered hearing is due to pressure 
on the labyrinth fluids, and in its turn on the ultimate ner- 
vous apparatus, or to the non-vibratility of the ossicles 
and membranes, so that a diminished impulse is conveyed 
to the acoustic nerve. I am aware that I have held the 
opinion that pressure on the nerve was the principal cause 
of deafness (7>. Am. Otol. Soc. y 1880). Pressure of the fin- 
ger on the eye will cause temporary diminution of sight, 
which is restored directly on removal of the pressure, 
although it is not instantaneous. Whether this would be 
the case if the pressure were continued for days or weeks I 
am unable to say; probably not. In the case of the ear the 
hearing is restored instantaneously on inflating the tympa- 
num, even though this condition may have been present for 
weeks together. The observations in intermittent bone 
conduction seem to point conclusively to the fact that ab- 
sence of free vibratility of the ossicles, the membrana and 




Fig. 16.— The lower represents the appearance of the ordinary clinical tuning-fork, 
the upper, the round tuning-fork, which produces a very low tone. Both are much 
diminished in size. 

the membrane of the round window is the main cause of 
defective hearing. To test the bone conduction with utter 
thoroughness would seem to require tuning-forks represent- 
ing every tone which is audible to the normal ear. 



THE DIFFERENT MODES OF TESTING THE HEARING. 

An exact standard of hearing is scarcely possible. The 
very young hear better than the adult or aged; those of 
high, intelligence, especially where the ear has been trained, 
hear better than others: musicians naturally belong to this 
class. A patient will hear the tick of a watch further in a 
small room than a large one ; if there is a stone or wood 
floor, and an absence of drapery at the windows, it enables 
•a person to hear at a greater distance than otherwise 



38 DISEASES OF THE EAR. 

Drafts of air through a room interfere with audition. 
When a person is in good health and spirits, with absence 
of any considerable fatigue or mental distress, the hearing 
is better than it otherwise would be. The watch, the voice, 
the whisper, and the snapping together of the thwnb-nail and that 
of otie of the fingers, are, with the exception of the tuning- 
fork, ordinarily sufficient to test the hearing. It is conve- 
nient to use the following abbreviations: R., right ear; L., 
left ear; H. D., hearing distance; w., watch; v., voice; wh., 
whisper; n., finger-nails; c, contact; p., pressed against the 
auricle, etc. 

The distance a normal ear hears with any one of these 
tests may be placed in the denominator of a fraction, and 
the distance any given ear may hear is placed in the nume- 
rator. If the hearing is perfect the numerator equals the 
denominator of the fraction, and is equal to unity, which is 
expressive of perfect hearing. To illustrate : H. D. R., w., 
§£ (assuming the watch to be heard forty inches), or hear- 
ing of the right ear, is by the watch only one half the nor- 
mal. If the patient hears the watch pressed on the auricle, 
then place the letter p in the numerator of the fraction; 
or, if on contact, then the letter c. is placed there. Dr. 
Prout, of Brooklyn, and Dr. Roosa, of New York, have 
done much to perfect this method, which is analogous to 
the tests used for vision. The test of the hearing by the 
watch is very uncertain. My own watch may be heard 
about five feet. A medical student once heard it at a dis- 
tance of twenty-three feet. More recently, a medical man 
came to me for treatment, saying that his right ear troubled 
him; he heard his own voice too distinctly on that side, and 
he thought the hearing was not quite as acute as it had 
been. I found he heard my watch at twenty-five feet. I 
then inflated his middle ear, and it sprung up to thirty-five 
feet, the highest degree of hearing I have ever met with. 
The test was made with the patient blindfolded, and the 
watch was alternately held in the air and then behind my 
back, and he readily detected the tick when held in the air, 
but failed to do so immediately when placed behind my 
back. The doctor remarked that in auscultation he often 
heard sounds that the most expert men with normal hear- 
ing failed to detect. We never expect our hospital patients 
to hear quite as far as others. The voice may be heard at 
least fifty feet in a closed room. The words should be 
spoken distinctly, in a middle tone, and not too rapidly. 



MODES OF TESTING THE HEARING. 39 

There will sometimes be found a very great discrepancy be- 
tween the voice hearing and that of the watch ; naturally we 
place a higher value on the improvement to voice hearing. 
This test is a valuable one for children or malingerers, as it 
cannot be proven whether the watch is heard or not ; but a 
pertinent answer to a question settles all doubts about the 
hearing. The whisper is a useful test, especially in a small 
room, where the voice is too well heard. The snapping of 
the thumb and finger nails together is useful as a test where 
the watch is not heard. I have seen the formula written, 
H. D. w., 4°8-, which expresses only a negative quantity. If 
the watch is heard in contact with the auricle, the finger-nails 
may be heard at about three feet. 

It may be pertinent to observe here that the hearing for 
the voice at the near point is several times in excess of ac- 
tual needs ; the frequent failure of people to hear the voice 
in ordinary conversation being a matter of carelessness, in- 
attention, or even dulness of comprehension. Many people 
lose considerable hearing without being aware of it. The 
above remarks refer only to aerial vibrations ; the tuning- 
fork tests of hearing will appear elsewhere. 

In the detection of one-sided deafness, tightly close the 
better ear with the finger or a piece of charpie, and accurately 
note the amount of hearing in this ear. This should be 
determined for both sides of the head. The problem naturally 
will be to determine which ear hears a given tone ; if one ear 
is normal this is sometimes well-nigh impossible. A case under 
observation, with absolute deafness in the right ear, furnished 
important data on which to base certain proportions. J. A., 
twenty-six years of age, at the age of four was knocked down 
by a runaway team. She was rendered insensible for a time, 
had convulsions, and was left with a permanent facial paralysis. 
No signs of disease of the ear, on inspection. The hearing of 
the left ear was perfect ; with this tightly stopped by the finger, 
she hears the snapping of the finger-nails at four feet on the 
left side and two feet on the right. The voice in ordinary 
tones is heard at thirty inches on the left side, and fifteen 
inches on the right. The whisper is heard ten inches on the 
left side and five inches on the right, the hearing distance being 
about half as far on the affected side as on that of perfect hear- 
ing. Any sound produced on the right side, and being heard, 
is unaffected in its intensity by closing the right ear. It fol- 
lows, then, that in a given case, with the better ear closed, and 
its hearing on either side being known, any increase in the 
3 



40 MODES OF TESTING THE HEARING. 

hearing of the affected ear, as previously found, must be placed 
to its credit. Many cases will arise where the suspected ear 
has some hearing, but an insufficient amount to be detected by 
the methods already mentioned. To obviate this difficulty, a 
hearing trumpet with a flexible tube may be used. 

The following case may serve to illustrate the point : E. B. 
D., set. fifty-five, had perfect hearing until July, 1883, when he 
fell from a ladder, a distance of thirteen feet, striking his head 
upon the hard ground. He remained unconscious for four 
weeks ; he bled from one ear, and subsequently had an ill- 
smelling discharge, which continued for several weeks. 
Tinnitus and vertigo have been constant symptoms. A firm 
step on the heel jars his ear unpleasantly ; had falls on account 
of the vertigo. No signs of disease on inspection. The better 
ear, the right, hears a watch at ten inches ; voice and whisper 
nearly normal ; had a " gathering " in this ear when a child. 
A great variety of tests were instituted to determine whether 
there was hearing even for loud noises in the left ear. With a 
hearing trumpet, having a flexible tube forty-five feet in length, 
extended through the crack of a slightly-opened door into the 
adjoining room a loud shout at the mouth of the trumpet was 
distinctly heard by the better ear. The same was true of a 
noise produced by striking a metallic tongue spatula against a 
large tuning-fork. It made no difference whether the tube was 
closed by pinching its walls together. If the sound became 
inaudible to the better ear, no sound whatever was heard. I 
conclude that were the tube sufficiently lengthened, so that a 
pistol were fired in front of the trumpet (not being within ear- 
shot of the good ear), it might have been heard by the affected 
ear. It will then be seen that tests for absolute deafness are 
extremely difficult to discover. 

If the tuning-fork be placed on the teeth or any part of the 
head, it may not be heard on the affected side ; but if that ear 
be closed, there may be some hearing. Again, if the tuning- 
fork be placed on the mastoid of the affected ear, or on the 
molar teeth of the same side, it maybe heard apparently in the 
affected ear, but in reality by its fellow. If it is heard by the 
worse ear, closure of the meatus will cause it to be heard 
stronger than before. I once had a patient who was very hard 
of hearing in his right ear, who insisted that he heard the tick- 
ing of a watch pressed upon the auricle. On closing the fellow 
ear the watch was heard more distinctly than before, proving 
that the left ear alone was possessed of hearing. 

Sometimes by placing the base of a powerful tuning-fork 



MODES OF TESTING THE HEARING. 41 

against the mouth of a hearing trumpet, especially if it be a 
metallic instrument, something may be gained by thus combin- 
ing aerial with bone conduction. 

Another test, spoken of by Knapp in the Arch. Utol. y vol. ix M 
pp. 509, 510, is this : Pass a vibrating tuning fork to and fro 
before the meatus, and in the regions of the " deaf points " 
there will be an interruption to the hearing, which, when moved 
quickly, will cause a noticeable break in the continuity of the 
audible vibrations, provided the hearing in the affected ear is 
moderately good. If this is decidedly lowered the phenomenon 
will not be observed, but at the same time the fellow ear is 
likely to hear the tuning-fork, and, for obvious reasons, without 
this peculiar interruption. By this test it is not possible to 
differentiate between entire absence of hearing and a consider- 
able degree of deafness. 

Many other tests for one-sided deafness have been used, but 
it is believed that those already mentioned will enable one to 
determine the state of hearing as perfectly as any known 
methods. The subject of simulated deafness may. be mastered 
by the application of the principles already laid down. This 
topic is extracted from an article, treating the matter more 
fully, with reference to the literature of the subject, in the 
N. Y. Medical Record, March 21, 1885. 

THE APPEARANCES OF THE NORMAL MEMBRANA TYMPANI. 

In order to appreciate the appearances of the membrana 
properly, it is well to remember some of its characteristics. 
Its vertical and horizontal diameters are about the same — 
8 to 9 mm., or 4 lines ; its longest diameter passes obliquely 
from before backward and upward, and is about 1 mm. 
longer than the other diameters. The obliquity of the mem- 
brane is indicated by the following statements : the upper 
wall of the meatus is about 3^ lines nearer the external 
opening than the lower, and the posterior wall 2% lines nearer 
the outer orifice than the anterior. The direction of the 
membrane will then be downward and inward, and forward 
and inward. It forms an angle of about 35 ° with the axis 
of the canal. In very young children this obliquity is much 
greater, so much so as to become nearly horizontal. Opposed to 
this proposition, however, is the following statement from 
Politzer, in his " Lehrbuch der Ohrenheilkunde," B. i. S. 22 : 

" The inclination of the drum membrane in children has 
hitherto been described as nearly horizontal. By means of 



42 DISEASES OF THE EAR. 

numerous measurements Dr. J. Pollak has shown this view 
to be erroneous, there being no perceptible difference in 
the inclination of this membrane in infancy and adult life." 
The color of the membrana is of a pearly gray, trans- 
lucent, and in very young children quite transparent. In 
the aged, however, it is often very opaque. Its color varies 
with that of the inner wall of the tympanum, which is ca- 
pable of reflecting light through the membrane and adding 
to it its own peculiar tint. In the very young the mem- 
brane is sufficiently transparent to see the long shank of 
the incus passing downward and backward, parallel with 
the malleus handle, and terminating at about two thirds 
its distance ; very rarely the lower portion of one ramus of 
the stapes may be seen. Other peculiarities of color may be 
observed, but will be mentioned elsewhere. The light reflex 
is a very important landmark indeed, 
and depends on the presence of two 
factors: ist, a normal state of polish 
of the dermoid (outer) layer of the 
membrane; 2d, on placing the point 
from which the light reflex appears 
upon such a position of the membrane 
as to reflect the light back to the ob- 
server's eye. Manifestly, every part 
Fig. 17. of a normal membrane reflects light, 

Normal membrana tympani. but the obliquity of most of the re- 
flecting surface prevents the rays returning to the observer's 
eye. Hence it follows that if a membrane retains its lustre, 
and any part of its surface lies at right angles to the axis 
of the canal, a light reflex must needs be observed. The 
naturally oblique position of the membrana would reflect the 
light downward and forward, so as to impinge on the antero- 
inferior wall instead of passing out of the canal to reach 
the eye. The cause of a change in the central position of 
the membrana, so that a reflex appears at the umbo, is the 
traction of the malleus handle. If any membrane be 
stretched upon a ring placed obliquely at the end of a tube 
resembling the meatus externus, and a stick be fastened to 
the membrane so that one extremity reaches to the centre 
while the opposite end is at the periphery, and this is drawn 
toward the far end of the tube, the membrane will be 
found to be dimpled or umbilicated at its centre precisely 
as at the umbo of the membrana tympani. Or, take a 
pocket handkerchief, fasten it tightly to a circular hoop; 




APPEARANCES OF NORMAL MEMBRANA TYMPANI 43 

place it very obliquely opposite a long tube, then catch it 
at the centre by the fingers and draw it sharply inward: 
the upper part will be more inclined than before, and the 
lower part will be so drawn inward that a small portion 
will present a surface at right angles to the axis of the tube, 
which, if a polished surface, would reflect a cone of light. 
The shape of the light spot will be somewhat triangular, 
with its apex towards the end of the malleus handle and its 
base extending nearly to the periphery of the membrane 
(its diameter is a little more than a line). A very frequent 
position of the light spot is nearly half-way between the cen- 
tre of the membrane and its periphery, but somewhat nearer 
the centre (Fig. 17). The light spot will vary in shape with 
the regularity of curvature of the membrane, and may be a 
somewhat rounded spot, a few small points, or even several 
linear reflections; this reflex forms an obtuse angle with 
the malleus handle. From what has been said it will 
readily be anticipated that a light spot may be found wher- 
ever the membrane falls into a position at right angles to 
the axis of the canal. If there be a cup-shaped depression 
in the membrane, the bottom of it must needs be at some 
point at right angles to the axis of the canal and reflect a 
light spot to the eye. By the same law, any elevation from 
bulging of the membrane would give a reflex from its most 
projecting portion. The short process of the malleus, for 
this reason, sometimes gives a minute reflex. The malleus 
handle passes downward and backward at an inclination of 
about 45 or 50 , and terminates at a point near the centre 
of the membrane, dividing it into two halves, of which the 
anterior is somewhat smaller than the posterior half. The 
short process is placed on the upper extremity of the malleus 
handle, and very near the periphery of the membrane. The 
neck of the malleus completes the area of membrane, while 
the head of the hammer projects far into the tympanum 
at its upper and somewhat anterior portion. The handle 
passes between the outer (radiate) fibres of the fibrous or 
middle layer and the circular (inner) fibres of the same 
layer. It terminates by a spatula-like extremity, which 
often appears as such on inspection. The short process 
seems, according to Troltsch, to be covered only by the 
dermoid or external layer of the membrane. The mem- 
brane is maintained in its concave position at the umbo 
by the traction exerted on the malleus handle by means of 
the tendon of the tensor tympani; the latter emerges from 



44 DISEASES OF THE EAR. 

an aperture in the anterior pyramid on the inner wall of 
the tympanum, passes across the cavity and is inserted 
into the malleus near the short process. By the settling of 
the membrane upon the knuckle-like projection of the short 
process, it is thrown into two slight folds — an anterior and 
posterior. The anterior fold commences at the short pro- 
cess, often with a rounded prominence resembling the 
short process itself, and passes downward, forming an acute 
angle with the manubrium, and terminates nearly opposite 
the extremity of the malleus handle, at the periphery of the 
membrane, and sometimes apparently merging itself with 
the meatus. In some instances it commences at a point 
above the short process, and in others somewhat below. 
This fold is frequently not sufficiently conspicuous to be 
seen except by a careful examination. 

There is also a posterior fold, commencing near the short 
process and extending backward, upward, and finally 
downward, forming an obtuse angle with the malleus 
handle. It is ordinarily less conspicuous than the anterior 
fold. The explanation of the cause of these folds is easily 
understood by taking a handkerchief, drawing it tightly, 
then thrusting a knuckle into it, when folds will be pro- 
duced resembling those of the membrana tympani. The 
inner extremity of the meatus terminates in a bony 
ring, into which the membrane is inserted. At its upper 
part a portion is lacking: this is called the Rivinian seg- 
ment. This hiatus is filled in by cutis from the meatus and 
mucous membrane from the tympanum. The Rivinian 
fora?7ien may occasionally be demonstrated passing from 
above somewhat downward, from a point just in front of 
the short process through the membrane, beneath the 
chorda tympani and tendon of the tensor. A small bristle 
may be passed into it. Occasionally air or tobacco smoke 
may be blown through it. The presence of this canal is 
denied by some, who claim that the appearance is due to 
arrest of development. ShrapnelVs membrane, or, as Shrap- 
nell has denned it, the membrana flaccida, is located as 
follows: Two bands extend from either extremity of the 
Rivinian segment and meet on the short process, thus form- 
ing a triangular space. This is filled in by cutis and mu- 
cous membrane. It is very yielding and readily moves to 
and fro, and serves to relieve the membrane of any sudden 
pressure which might otherwise rupture it. TroltscJis 
Pocket may be thus described: A supplementary leaf of the 



DISEASES OF THE AURICLE. 45 

drum membrane applied to its inner surface on the upper 
part of its posterior half, irregularly triangular in shape, about 
3 or 4 mm. in diameter, and arises just behind the osseous 
border giving attachment to the membrana, and extends to 
the manubrium; it opens below and forms a " pocket" or 
cavity. The chorda tympani nerve runs along its posterior 
concave border. 



DISEASES OF THE AURICLE. 

PRELIMINARY OBSERVATIONS. 

The auricle, with the exception of the lobule, is chiefly 
composed of cartilage: this is complicated in form, in 
order to give its peculiar shape to the organ. It is cov- 
ered by perichondrium, the fibres of which pass into the 
substance of the cartilage, form anastomoses, amongst 
which are found small cartilage cells (Strieker). 

The cutis of the auricle covers the cartilage, and by its 
duplicature forms the lobule. Over the whole surface 
downy hairs are found, into the sheaths of which sebace- 
ous glands enter. In the concha these glands are of 
greater size than elsewhere, and may be seen by the aid of 
a magnifier. Sma^l sweat glands are found on the surface 
of the auricle, chiefly on the side next to the skull. On 
the concave surface of the auricle the subcutaneous con- 
nective tissue forms a thin layer firmly united with the peri- 
chondrium, causing the skin to be immovable; but on the 
convex side it is thick, and the skin is quite movable. 
The lobule is composed of skin, connective tissue, and fat 
cells. The cartilage of the auricle is continuous with the 
cartilaginous portion of the meatus externus. The auricle, 
with its helix and its antihelix, its tragus and antitragus, 
its fossa of the helix and its fossa of the antihelix, its in- 
cisura intertragica and its rounded and graceful lobulus, 
is indeed a beautiful appendage to the organ of hearing. 
I do not remember to have ever seen a portrait painting by 
even the most renowned master in which the auricle is 
even respectably delineated. Only a few persons possess 
auricles having the classical type. I cannot say that it has 
any special function other than to collect by its concave an- 



46 DISEASES OF THE EAR. 

terior surface the sonorous undulations for their passage to 
the membrana tympani through the external auditory 
canal. Many theories have been broached pointing to a 
different function, but when we habitually observe people 
who are hard of hearing, passing their hand behind the 
auricle to prop it forward to catch the sound, we are rea- 
sonably certain that its function is, like the hearing-trum- 
pet, to collect and convey sounds to the organ of hearing. 



ECZEMA OF THE AURICLE. 

This is a species of catarrhal inflammation of its integu- 
ment. The parts seem often to be invaded by the eczema 
of neighboring regions. Notably is this the case with 
eczema of the face, when the auricle is frequently attacked 
with the disease. The same is true of E. capitis. An acrid 
discharge from the ear frequently induces an eczema of 
the auricle and meatus. Exposure to cold is sufficient to 
develop it, so also is uncleanliness. Any depressing in- 
fluences may predispose to it. It is frequently met with in 
those of strumous habit. Dentition seems occasionally to 
cause it. Scarlet fever and measles have been known to 
produce it. 

Symptoms. — The auricle is intensely red, tender, hot, tense, 
and considerably swollen; the vesicles characteristic of the 
disease are well developed, and give rise to a fine dis- 
charge, which dries into crusts, falls off, and leaves a dull 
red surface beneath. Frequently this is developed into ec- 
zema impetiginodes, when the ear becomes hypertrophied, 
and small abscesses are formed. The acute variety is more 
frequently seen in children. In the adult the chronic form 
is more frequently seen, when few or no vesicles are visi- 
ble, the auricle being dry, more or less scurfy, with fissures 
here and there, and accompanied by considerable hyper- 
trophy and distortion in the shape of the organ. In this 
state the disease is very prone to invade the meatus, and 
extend to the drum membrane. 

Frequently considerable deafness results, accompanied 
by tinnitus aurium and a stuffy feeling in the ear. This 
condition is often very intractable to treatment. 

Diagnosis. — However long eczema may have continued, 
there will be found somewhere in the history evidence of 
its having been a " moist " disease. Usually the vesicular 



TREATMENT OF ECZEMA OF THE AURICLE. 47 

stage has passed before the physician is called. A redness 
of the part will have been observed, which had a tendency 
to " weep" or "discharge." The minute vesicles may of- 
ten be seen on the edges of a patch of old eruption. We 
often have a moist, swollen condition behind the ear, 
and on the convex surface of the auricle at its union with 
the side of the head, an intertrigo, which is the result of the 
friction of the auricle against the head, and by its moist 
surfaces somewhat resembles eczema, but there are no ves- 
icles, and the cause of the trouble is evidently that of inter- 
trigo. Herpes, with its small bullae collected upon a red 
base, which do not break as in eczema, but shrivel away, 
with absence of light yellow crusts, will cause no error in 
diagnosis. 

Treatment. — The first indication in the treatment of the 
acute form of eczema is the avoidance of all irritating ap- 
plications to the parts, and to refrain from too much treat- 
ment. The excessive itching and burning must be re- 
lieved, and it is difficult to state what remedy will best 
fulfil this indication until it is tested. When the part is 
covered with scabs they must be removed by poulticing, as 
with flaxseed, bread and milk, etc., but do not allow the 
poultice to remain sufficiently long to macerate the parts, 
which will add to, rather than diminish the tendency to 
discharge. To allay the irritation of the parts, the follow- 
ing remedies are found to be serviceable: Wash the part 
several times daily with bran infusions, or even cold water, 
being careful, however, to keep the meatus stopped with 
cotton for fear of the damaging effects of the cold upon 
the tympanum. Acetate of lead and powdered opium, a 
scruple of each to the pint of boiling water, is a very 
soothing application; use by dipping lint into the lotion 
and laying it on the parts, with frequent renewals. Five 
grs. zinci sulph. with two grs. of morphine to an ounce of 
water, is also good to allay irritation. Common whiting 
mixed into a thin paste and brushed on the part does well. 
After a little time we may commence to use remedies cal- 
culated to diminish the discharge; care, however, needs to 
be taken not to do too much, for greater heat and inflam- 
mation may result from injudicious use of such remedies. 
Bismuth, camphor, and starch, of each equal parts, may be 
sprinkled on the auricle, but must be washed off once or 
twice daily. Vaseline alone, or with finely powdered red 
oxide of mercury, one or two grs. to the 3 i, may be ap- 



48 DISEASES OF THE EAR. 

plied several times daily. The linimentum calcis some- 
times is successful. In washing off the parts frequently, a 
very weak lotion of soda in tepid water may be used, or 
even white Castile soap. In Vienna the soap treatment is 
much in vogue, where common yellow soap is rubbed into 
the part for the purpose of exciting a new action. This 
latter idea, however, must be used somewhat cautiously. 
Some recommend washing the ear with gruel. 

When all vesicles are removed and the part is red and 
not excessively hot, with infiltration and swelling of the 
subcutaneous connective tissue, rather strong stimulants 
may be used. For this purpose a solution of arg. nit., grs. 
x to xxx to the ounce of water, may be painted on the 
auricle every two or three days. Tr. iodine I have found 
perhaps the best remedy for this purpose. If an excess of 
it is applied considerable burning pain may result. 

After the epidermis begins to exfoliate, Wilde is in 
favor of pricking the part here and there with a sharp 
lancet. I have no experience in this method, and feel a 
little doubtful about its utility. As the parts need at all 
times to be protected from the air, the suggestion to apply 
collodion is a good one, especially in the latter stages of 
the disease. It is like strapping parts, to diminish the ten- 
dency to relaxation, and give support. A little oiled silk 
bag may be used to protect the part from the air during 
the use of the remedies already suggested. 

The co7istitntional treatment is very important. As we are 
likely to deal with children more frequently than with 
adults, the kind and quantity of food taken will be of great 
importance. Nothing should be allowed which is indi- 
gestible or innutritious. The periods of eating should 
be regular. Frequent bathing and the most careful atten- 
tion to cleanliness should be practised. The bowels need 
attention, and also any acid or acrid condition of the 
stomach. 

Rhubarb and soda, or magnesia calcinat., hyd. c. creta, 
or some other form of mercury, will readily occur to the 
practitioner as being appropriate. Tonics, iron, and cod- 
liver oil will frequently be required; nor must fresh air be 
neglected, nor whatever tends to better the general consti- 
tution of the patient. In chronic cases Fowler's solution 
must be used; iodide of potass, is sometimes indicated. 



HERPES ZOSTER AURICULARIS. 49 



HERPES ZOSTER AURICULARIS. 

Herpes zoster of the auricle, according to Tilbury Fox, 
is identical with that of the nose and mouth, and does not 
essentially differ from the disease in other parts of the 
body. It is characterized by the presence of vesicles larger 
than those of eczema, distinct from each other, and seated 
on an inflamed base, which as a rule do not rupture. The 
duration of the vesicles is seven or eight days. Severe 
neuralgic pain precedes their formation, lasting for one* or 
two weeks, which usually subsides upon the appearance 
of the eruption. The latter is accompanied by heat, ten- 
sion, and burning; fever usually ushers in the attack. Dr. C. 
H. Burnett, in his Treatise on the Ear (Phil., 1877), quotes 
Prof. Gruber, in "Die Blaschenfleschte am Ohre.," Monats- 
schr. f. O., Mai, 1875, as having observed this disease in 
the form of an idiopathic affection, which is of very great 
rarity. He speaks of it as involving the skin of the auri- 
cle, meatus, membrana, and even the lining of the tym- 
panum; for it is sufficiently well known that herpes 
involves mucous membranes as well as skin; when this is 
the case considerable deafness results. Dr. Burnett also 
quotes Dr. J. Orne Green, in the Transactions of the Ameri- 
can Otological Society for 1874, as alluding to a case of neu- 
ralgia of the ear, which resulted in an herpetic eruption 
"over the anterior surface of the helix." He in turn also 
quotes Dr. Anstie, in the Practitioner, as reporting a case 
of zoster of the nerves supplying the tragus and meatus. 
Dr. Burnett also speaks of a case of herpes zoster of 
the tragus in a young lady 18 years old, and also of a 
man who had herpes of the meatus and of the tragus. Ac- 
cording to Gruber's article, the nerves involved in this 
affection are the auricularis magnus and the auriculotem- 
poral; and the eruption appears more frequently on the an- 
terior and upper surface of the auricle, the vesicles being 
more numerous over tracts innervated by filaments of the 
auricular branch of the pneumogastric nerve. 

Herpes of the auricle is developed in the same manner 
as in other parts of the body. There seems no doubt but 
that it is a disturbance in function of the sympathetic sys- 
tem of nerves, especially those presiding over the circula- 
tion, the vaso-motor. 

As causes of this disturbance we may enumerate the fol- 



50 DISEASES OF THE EAR. 

lowing: The common phenomena of taking cold, with its 
accompanying herpes labialis, or "cold sore," will give a 
good idea of its nature. Inflammation of the deeper parts 
of the ear of a catarrhal nature, or a general catarrh, pneu- 
monia or fevers, ague, direct exposure to cold, emotional 
disturbances — sometimes the administration of arsenic will 
cause it. The disease resembles somewhat an eruptive 
fever. 

The diagnosis is not difficult; the neuralgic pain and fever 
preceding the eruption are very characteristic. The vesicles 
are larger than those of eczema and smaller than those of 
pemphigus, and are situated on an inflamed base. They 
do not rupture, except when in the meatus. The short 
duration and regular course of the disease sufficiently 
differentiates it from other similar affections. 

The prognosis is altogether favorable, except in the very 
feeble or those who have been debilitated by extreme age ; 
then great effort needs to be made to keep up the strength 
of the patient. The vesicles after rupturing frequently 
leave large ulcers, which are a considerable time in heal- 
ing. The hearing when affected recovers slowly but per- 
fectly after a few weeks. 

Treatment. — The parts simply require protection from 
irritation and exposure, as the disease naturally tends to- 
wards recovery. It is on the whole better not to rupture 
the vesicles. The auricle may be anointed with vaseline, 
then sprinkled with flour, the whole to be covered by ab- 
sorbent cotton. Vaseline |i, plumbi acetat. gr. v ad x, 
is a good application. Coating with collodion is also 
serviceable. If the parts are painful, diachylon salve with 
morphine may be used, spread on lint and applied. Cam- 
phor and belladonna liniment, of each equal parts, may be 
used. In the meatus the vesicles are always ruptured, and 
a moist condition is the result. Some astringent will be 
needed on this part. Gruber, in the article referred to, 
recommends sulph. zinc. Arg. nit. painted on the canal will 
be serviceable. Plumb, acet., 5 to 10 grs. to the ounce of 
water, is a good remedy. If the neuralgic element is pro- 
minent it will be proper to use hypodermic injections of 
morphine, or any other means calculated to relieve pain. 
Stimulants and tonics may be necessary to meet any symp- 
toms of depression. Careful attention to the patient's 
food will be necessary; a full and nutritious diet must be 
prescribed, and perhaps alcoholic stimulants. 



ERYSIPELAS OF THE AURICLE. 5 I 



ERYSIPELAS OF THE AURICLE. 

The auricle is occasionally the seat of erysipelas. This 
is of the simple variety. It presents the same symptoms as 
that disease found elsewhere. It is ushered in by febrile 
symptoms more or less severe, lasting two or three days ; 
on the appearance of the eruption the auricle has a burn- 
ing or smarting sensation, with a feeling of tension; it is 
red, swollen, puffy, and shining. The edges of the patch 
are raised, the parts are tender and hot. In two or three 
days the redness increases, blebs form; these burst and 
dry into scabs. In five or six days convalescence com- 
mences, and the surface becomes yellowish and the cuticle 
becomes somewhat detached. The hearing may tempor- 
arily be diminished by closure of the meatus from swelling. 
This disease is caused by extension from other parts to the 
auricle, as when the face or scalp is involved. Cold is a 
sufficient cause. Any species of traumatism, especially 
when the patient is in a depraved state of health, may ex- 
cite it. Leech bites sometimes result in erysipelatous in- 
flammation, as I have in a few instances verified. In 
Bright's disease traumatism is peculiarly liable to induce 
it. Women are more subject to the disease than men. 

Its duration is from eight to twelve days. The prognosis 
is altogether favorable, there being, as far as I know, no 
destructive processes, as in the phlegmonous varieties. 

Diagnosis. — It is not likely to be confounded with any 
other disease except erythema, from which it maybe distin- 
guished by the absence in the latter of the tense, shining, 
smarting blush, and the implication of the subcutaneous 
connective tissue, so characteristic of erysipelas. 

Treatment. — The pyrexia may be managed in the ordi- 
nary manner. It will be well to avoid any cold applica- 
tions, on account of harm being likely to result to the hear- 
ing. In the earlier stages, a weak lead and opium wash 
may be used, or poppy fomentations. Protect the part 
from cold, and even apply heat if necessary. In a later 
stage, tr. of iodine painted upon the part is very service- 
able ; it may cause some pain, but subsequently it will 
afford much relief to the burning and smarting. The con- 
stitutional treatment is very important. Tr. ferri chlor. in 
large doses, four or five times a day, either with or without 
quinine, is strongly indicated. Stimulants may be needed 



52 DISEASES OF THE EAR. 

to keep up the strength. The greatest care of the nutri- 
tion is necessary. 

HORNY GROWTHS ON THE AURICLE. 

These are occasionally seen; I have observed two or 
three cases. It seems to be an hypertrophy of the epider- 
mis. The one I distinctly remember had a growth on the 
upper part of the helix, more than half an inch in length, 
tapering at its extremity, and of horn-like hardness. At 
its attachment on the auricle, it was moderately soft, 
and resembled cartilage. It occurred in a young man who 
first noticed it about seven months previously. It was 
somewhat tender to the touch at its attachment. The 
color was yellowish, and it had the appearance of true horn. 
I removed it by an incision made somewhat deeply into 
the auricle, without difficulty; as far as I know, it never 
returned. Sometimes the same development may be found 
in other parts of the body. By a case reported by Dr. A. 
H. Buck, in The Transactions of the American Otological So- 
ciety for 1871, page 18, it would seem that if the base of the 
tumor is not fully removed, it may be expected to return. 
Dr. Buck describes his case as " a blunted, horn-like 
protuberance, three fourths of an inch long, and nearly 
as broad at its base; it sprang from the upper and pos- 
terior part of the left helix. ... At the extremity and 
middle portion it was hard like horn, but near the base 
it could be easily compressed, though yet comparatively 
hard. . . . The line of demarcation between the growth 
and the normal skin was very abrupt. There was no pain 
to patient, or tenderness on pressure. It was removed and 
did not return. The young man had been in the habit of 
paring it off with a razor. On the eyelid corresponding to 
this ear was a small sharp point resembling the aural 
growth at an earlier stage." Dr. Burnett, in his Treatise 
on the Ear, reports the following case which occurred in 
his practice : A horny growth was observed on the upper 
and outer portion of the helix of the left ear, in a large, 
strong man, forty-five years old ; it was of smaller size 
than in Dr. Buck's case. The patient picked it and it grew 
larger ; it caused no inconvenience. He disappeared from 
observation. 

INTERTRIGO AURICULARIS. 

This is a disease peculiar to children. It consists of an 



TREATMENT OF ERYSIPELAS OF THE AURICLE. 53 

excoriation behind the auricle, commencing in the sulcus 
corresponding to the point of attachment of the auricle to 
the side of the head. The part is always moist, except 
occasionally when it is covered with scabs. If left to 
itself, it may extend and even develop into an eczema, 
or a disease closely resembling it. It depends on a thin, 
irritable skin, found in the healthy or strumous sub- 
ject. Moisture and uncleanliness of the part favor it, but 
the direct cause is friction between the posterior surface of 
the auricle and the side of the head, precisely as in the 
same disease when affecting the groins of little children or 
infants. Too much head covering, which is likely to press 
the ear against the head, with moistening of the part by 
prespiration and accompanied by uncleanliness, is probably 
the direct cause of the trouble. 

The treatment consists in removing the conditions giving 
rise to the disease, and protecting the excoriated parts. 
The latter indication is fulfilled by sprinkling powdered 
starch on the denuded surface, previously cleansed by 
bathing with tepid w T ater, aud a small addition of baking 
soda. Vaseline applied to a bit of lint or absorbent cotton 
may be sufficient to cure. Oxide of zinc, in powder, added 
to seven or eight parts of starch, is a good "drying" ap- 
plication. A bit of lint saturated with camphor water and 
borax will be of service. 

3$ Aqua Camph § i. 

Sod. biborat. gr. x. 

M. 

Vaseline and plumb, acet., one gr. of the latter to the 
drachm of the former, is a good application. When the 
excoriation is diminished, tr. iodine painted lightly over the 
part may be recommended. A coating of collodion will 
sometimes so protect the part as to cure by one applica- 
tion, but there must not be an excessive discharge, or the 
coating will be removed. In children of the lower class 
cleanliness must be insisted upon. 

FIBROUS TUMORS OF THE AURICLE. 

These are usually found in the lobulus, but may exist in 
other parts of the auricle. They are of fibrous hardness, ( 
somewhat paler in color than other parts of the ear, and 
more or less nodulated. They are also indifferently called 
fibro-sarcomatous or myxo-fibromatous tumors. The size 



54 



DISEASES OF THE EAR. 



of these growths varies from that of a large pea to a hen's 
e gg (Fig. 1 8) ; although in some cases they are found de- 
pending from the auricle of sufficient size to touch the 
shoulder, presenting a huge and horrible appendage to the 
ear. 

The cause of these growths is an inflammatory proliferation 
of the connective-tissue elements of the part, the result of 
some form of irritation. This is generally dependent on 
the practice of wearing ear-rings — 
sometimes from their great weight, 
as in those worn by many semi-bar- 
barous races, as the African or Indi- 
an. In other instances the irritation 
seems to result from the use of base 
metal in the earring (Roosa), or 
I \ this factor combined with a possi- 
lli^B IH' 'H I ^y strumous diathesis, so often 

found in mulattoes in this country, 
in whom the affection is prevalent 
(Turnbull). 

In some cases, however, I have 
seen inflammation and a tendency 
to fibrous proliferation in the lobu- 
les of the ears from simply piercing 
them and drawing a thread through 
the aperture preliminary to the in- 
sertion of the earring. Whether the 
process commences by the forma- 
tion of granulations at the borders 
Fibrous Tum^jf^the^ Auricle. of the perforation, as suggested by 
Gruber, or within the substance of 
the lobulus, is difficult to determine. A process almost or 
quite identical with that found in ordinary fibromata of 
the lobulus is sometimes seen in other parts of the auricle. 
Thus Agnevv reports a case of myxo-fibroma of the auricle 
as follows: 

C. S., aet. ii, received a scratch from a toilet pin upon the 
left auricle when two years of age. The resulting scar at 
the end of eighteen months reached the size of a buckshot. 
It was removed by the knife. Almost immediately a tumor 
returned in the old place, and at the end of two years was 
about three times the size of the old tumor. This was re- 
moved. At the end of two years more, another tumor about 
twice the size of the second one was removed. Some time 




FIBROUS TUMORS OF THE AURICLE. 55 

after this still another tumor had grown to such an extent 
as to involve most of the auricle except the lobulus, giving 
it a peculiar nodulated appearance with wavy outlines. 
The whole of this, with the cartilage of the auricle and 
most of that of the meatus, was removed. There remained 
a little skin and the lobule only. The wound was closed 
by sutures in such a manner as to form a rudimentary 
auricle. It returned again, however; but, as is the case with 
this class of tumors, it was benign in character, it was 
advised that it be again removed. This tendency to return 
is mentioned by many authors. Knapp, in the Archives of 
Otology, vol. iv., in speaking of Fibroma of the Lobule of 
the Ear, concludes that the recurrence of these tumors is 
mainly due to the fact of incomplete removal, as in one of 
his cases a portion of the tumor was left so as to make a 
better flap. The result was that the tumor soon grew 
again, but after a second and complete removal there was 
no recurrence. From the records of a large number of 
cases where the removal has been done with apparent thor- 
oughness, but where the tumors have frequently recurred, 
it would seem that there was a tendency to recurrence of 
the growths not to be always prevented by thoroughness of 
removal. The microscopical appearances of these tumors 
are those of a condensed "connective tissue with intersect- 
ing yellow elastic fibres, with few but strongly developed 
blood-vessels running through it " (Bertholet, Transactions 
of American Otological Society, 1871). According to some 
authors (Knapp, 1. a), " the softer and semi-transparent inter- 
spaces between the trabecles (of fibrous tissue) contained 
a large quantity of roundish, spindle-shaped, and stellate 
cells, which anastomosed with one another, and were sepa- 
rated by an abundant homogeneous or finely striated in- 
tercellular substance." Little need be said about treatment. 
If the growths are small and not unsightly, it may be 
proper to refrain from operation, but otherwise removal 
should be accomplished at once. If the growth is in the 
lobulus, a V-shaped incision may be made, using a stout 
pair of scissors or a scalpel for the purpose. The scalpel 
will make an incision more likely to heal kindly than the 
scissors. Closing the wound with sutures is all that remains 
to be done. In the case herewith reported, it will be seen 
that the whole of the cartilaginous portion of the auricle 
and most of that of the meatus was removed in the extir- 
pation of the tumor. 
4 



56 



DISEASES OF THE EAR. 



HEMATOMA AURIS; OTHEMATOMA. 



The first symptom of this affection is a swelling of the 
auricle, with redness, burning pain, and sense of distension. 
After a few hours or a day or two the blood tumor makes 
its appearance. This has a somewhat livid red color, or it 
may be little changed from that of the normal auricle. It 
varies in size from a filbert to a hen's egg, and occupies 
the concha as a rule, but may occasionally make its appear- 
ance higher up. It never invades the lobule. The blood 
effusion is usually beneath the perichondrium, but some- 
times it may be within the substance of the cartilage itself. 
When of considerable size, the tumor may convert the con- 
cave surface of the auricle to an even rounded convexity, 
occupying every part of the latter except the helix. This 

tumor is for a few days attend- 
ed with signs of inflammation, 
as burning pain and sense of 
distension in the auricle; but 
after a week it becomes quite 
inactive and slowly subsides, 
and in from two to four weeks 
has disappeared. Sometimes, 
however, an abscess forms. It 
spontaneously ruptures in a cer- 
tain proportion ol cases. These 
usually have a more favorable 
termination than where inci- 
sion has been made. A few 
end in complete absorption of 
the effusion, with very little 
resulting deformity. 

The Etiology and Pathoge?iesis 
is not well understood. The 
disease certainly occurs in the 
sane as well as the insane, al- 
though without doubt it is 
more frequent in the latter. 
The characteristic symptom, hemorrhage, evidently does 
not occur spontaneously in perfectly sound ears, and where 
there is no brain disease, even though traumatism has been 
an element of causation. 

The effect of traumatism in the perfectly healthy subject 
is worthy of note — there is no characteristic hemorrhage. 




Fig. 19. 

Othematoma (Gruber.) 



HEMATOMA AURIS. 57 

Virchow, Hun, and many others who have written on the sub- 
ject, seem strongly of the opinion that the auricle is in some 
way prepared for the hemorrhage by softening of its car- 
tilage into a viscid material, with the development of an ex- 
cessive number of blood-vessels of the perichondrium, with 
increase in their size, which would tend to produce sponta- 
neous hemorrhage, or one from very slight exciting causes. 
A depression of the vital energy of the part from any cause 
is a factor. Many cases evidently depend on some form 
of cerebral disease. Brown -Sequard, in a lecture in the 
University of Pennsylvania Oct. 10, 1872, (TV. Am. OtoL 
Soc.j 1873), states that othematoma has a nervous origin, 
and is the result of disease of the base of the brain, and is 
usually found in the paralysis of the insane. It may be 
produced artificially in animals by irritation of the resti- 
form body. In the insane he states that the tumor is on 
the side on which the brain is found to be diseased. Some 
form of irritation of the sympathetic nerve inducing hy- 
peremia of the cerebral vessels, together with those of the 
auricle, is regarded by some neurologists as a sufficient 
cause. 

The Diagnosis may easily be made from the fact of there 
being a bloody tumor in the auricle, with fluctuation, 
which has made its appearance sooner after the first symp- 
toms than would be possible for a fluid product of inflam- 
mation to develop. The amount of pain and inflammation 
is much less than in perichondritis. This, like the latter 
disease, never invades the lobulus, for there is no doubt but 
this is a disease of the cartilage and its perichondrium. 
Its duration is much shorter than that of perichondritis, 
and never commences in the tympanum and meatus, as 
the latter frequently does. In later stages, where suppura- 
tion occurs, there will be true perichondritis, but the symp- 
toms in the first stages will indicate its true nature. In 
some cases of erysipelas of the auricle with great swelling 
there may be some resemblance to this affection, but the 
helix will be swollen at least as much or more than the 
other parts of the auricle, and the color will be intensely 
red. Moreover there will be swelling of the posterior sur- 
face of the auricle — an unusual symptom in hematoma. 
In the latter affection, too, the swelling will be quite round, 
even, and more bladder-like than in erysipelas, and also 
quite in contrast to the nodular swelling of perichondritis. 
Its duration being only a month or even less, is quite in 



58 DISEASES OF THE EAR. 

contrast with that of perichondritis, which is often six 
months in recovery. 

The Prognosis is favorable as far as the hearing is con- 
cerned. Few cases recover without deformity. No treat- 
ment so far devised seems to prevent this. In a few in- 
stances where the hemorrhage has been moderate in ex- 
tent and no rupture has occurred, nor incision been made, 
very little deformity results; but these cases are quite ex- 
ceptional. There seems little or no destruction of cartilage 
as in perichondritis, except in very rare cases of abscess. 

With the view of adding to our knowledge of the nature 
of haematoma auris, I addressed a note to Dr. Ralph L. 
Parsons, of Greenmont, Sing Sing, N. Y., formerly physician- 
in-chief to the Lunatic Asylum on Blackwell's Island, N. Y., 
and also of the Flushing Asylum for Lunatics. His reply is 
as follows : 

"Greenmont, Nov. 30, 1882. 
" Dear Doctor Pomeroy: 

" Your letter asking an expression of my personal views 
on haematoma auris has been received. 

" My observation of haematoma auris has been entirely 
confined to cases occurring in the insane; and I am disposed 
to think that the disease occurs very rarely in the sane. 
My own experience has been to the effect that insane pa- 
tients who have haematoma auris do not recover. My con- 
clusions have been that the disease usually depends upon 
a grave deterioration of the nervous system as a cause. 
While the local disease may possibly be caused by a local 
injury in a healthy person, I have seen no such cases, and 
think they must be of exceeding rarity." 

Treatment. — The propriety of incising the tumor and evac- 
uating its bloody contents is somewhat doubtful. It would 
seem, at least on theoretical grounds, that if the tumor was 
destined to spontaneous rupture this should be anticipated 
by a free incision. Again, the difficulty confronts us, that 
it is not always possible to determine whether a given case is 
liable to spontaneous rupture or not. If the tumor is of mod- 
erate size, showing no tendency to rupture, and its disap- 
pearance by absorption is probable, it should not be inter- 
fered with. Where the extravasation of blood is extensive, 
and accompanied by considerable distension of the parts, 
and possibly by pain, with an undoubted tendency to still 
further separate the perichondrium from the cartilage, a 
free incision is certainly indicated, opening well the blood 



TREATMENT OF HEMATOMA AURIS. 59 

cavity so that it may receive proper treatment. This cav- 
ity may be thoroughly washed out with tepid water at 
least once daily. Sometimes a stimulant or astringent 
may be used in conjunction with the tepid water. Carbolic 
acid, one drachm to the pint of water, may be injected 
daily, or tr. of iodine may be used to swab out the cavity. 
Frequently these astringents irritate too much, and do not 
fully answer our expectations. Pressure by means of a 
roller bandage passed across the top of the head and under- 
neath the chin, and enclosing the auricle, answers very 
well. Place a bit of absorbent cotton behind the auricle 
and another in front; then lay the pinna against the side of 
the head and apply the roller — just tight enough to be 
comfortable to the patient ; remove often enough to keep 
the parts clean and the bandage snugly applied. In the 
earlier phases of the disease, if it is decided not to incise, 
a variety of measures may be adopted to subdue any inflam- 
mation and promote absorption. Dr. Kirkbride, physician- 
in-chief to the Pennsylvania Hospital for the Insane, thus 
writes to Lawrence Turnbull: "The best treatment that I 
have tried has been the application of ice to the tumor from 
the very commencement." This, he thinks, "prevents the 
enlargement which otherwise is pretty sure to occur." Dr. 
John Curwin, of the Pennsylvania State Lunatic Asylum of 
Harrisburg, finds tr. of iodine painted on the auricle once 
or twice a day the best treatment for haematoma auris 
(Turnbull, "Diseases of the Ear," pp. 138 and 139). Very 
few neurologists are in favor of incisions in this affection, 
and most of them believe that, whatever is done, considera- 
ble deformity is likely to result. 



PERICHONDRITIS AURICULA. 

This affection may appear as a primary inflammation of 
the perichondrium, commencing usually in the concha, but 
it may develop from any portion of the front part of the 
auricle except the lobulus. In some cases the cartilage 
will be found softened at the point from which the inflam- 
mation first arises. Again, the perichondritis plainly de- 
pends on an inflammation of the meatus or tympanum, 
which involves the perichondrium of the auricle by exten- 
sion outward. The swelling may be of a bright red color, 
although not always, and quickly extends to the whole 
anterior surface of the auricle except the lobule. Fre- 
quently, however, inflammation escapes the helix. 



60 DISEASES OF THE EAR. 

In the earlier stages the process is quite rapid, and is ac- 
companied by much heat, pain, and sense of fulness in the 
auricle. In the subacute stage its progress is slow, being 
sometimes more than six months in duration, and often 
very painful. 

In the more severe cases a large portion of the cartilage 
may be denuded of its perichondrium, and sometimes .com- 
pletely destroyed over a considerable area. This results in 
very great deformity to the auricle. In this class of cases 
the auricle may be the site of an immense abscess which 
subsequently may be partially filled with granulations. In 
other cases the cartilage is thickened by inflammatory pro- 
liferation and becomes much distorted in shape, and may 
obliterate the normal outlines of the auricle. In milder 
forms of the disease the inflammation may terminate in 
resolution after a duration of a few weeks only (three to six). 
Symptoms. — In the severer forms of the disease an inflam- 
matory swelling may be noticed in the meatus, which 
gradually extends outward, involving first the concha, then 
the greater part or the whole of the front of the auricle 
except the lobule, when it will be swollen so that the nor- 
mal configuration of the parts will be obliterated and the 
pinna will be nearly flat or somewhat irregularly convex 
on its anterior surface. In some cases the posterior surface 
of the auricle may be involved. The 
color of the swelling will be red or 
reddish, in many instances inclining 
to a bright rather than a livid red; in 
other cases there may be little change 
in color. The burning, smarting, and 
in some instances throbbing pain, 
may be so great as to necessitate the 
use of anodynes for relief. Where 
pus forms there is no difficulty in 
detecting it by the sense of fluctua- 
tion, but sometimes there is no pur- 
Fig. 20. ulent formation, and the ear may 

Auricle of j. s., showing the have some of the signs of fluctua- 
sweiiing posterior^. tion, without, however, proving the 

presence of pus. These signs will be more like a boggy or 
doughy sensation to the touch, similar to that which is ob- 
served in cellulitis, with considerable swelling over the 
mastoid. If the disease develops secondarily to an otitis 
media or otitis externa, there is likely to be a discharge 
from the meatus. 




PERICHONDRITIS AURICULA. 



61 



At an advanced stage of the inflammatory swelling, if the 
presence of pus be suspected and an incision made, a 
glairy, somewhat bloody fluid will be evacuated, which 
may or may not contain a small amount of pus. 

This will indicate pretty certainly, according to Virchow 
and others, that we have to deal with an inflammation 
of the cartilage. In the course of the affection large 
quantities of this fluid may be evacuated. In some in- 
stances the swelling of the auricle will be enormous, 
when it may be seen to stand out at right angles to the 
side of the head. In later stages the anterior surface of 
the auricle may have a nodular appearance, simulating 
malignant disease. The inflammation may extend to 
neighboring parts, and result in abscesses, enlarged 
glands, etc. The resulting deformities are very un- 
sightly, altering the shape of the auricle in some instances 
past recognition. The helix is less likely to be deformed, 





Fig. 2i. 

Shows the anterior surface of the 
auricle of J. S. 



Fig. 22. 

Auricle of J. S. after recovery, and 
showing the resulting deformity. 



but it may be, as seen in the appended cut. As this is an 
affection of the cartilage, the lobulus, having no cartilage 
in its structure, will be unaffected — a point to which Dr. 
Knapp has called attention. The cut will also show this. 
One point to which Dr. Pooley calls attention is, that the 
auricle is peculiarly liable to perspiration as a consequence 
of this affection. As far as I know, the hearing is un- 
affected. It will be seen that this disease has some points 
of resemblance to hsematoma auris or othematoma. The 
latter is also a disease of the cartilage in many instances; 
but the constant hemorrhages of this affection are not 
present in the former. Perichondritis may be secondary to 
disease of the tympanum or of the meatus. A furuncle in 



62' DISEASES OF THE EAR. 

the latter may lead to the development of this affection, or 
even the rare instance of a furuncle in the auricle may- 
do so. Often it is idiopathic, again it is traumatic. It has 
never been observed in the insane. The swelling in peri- 
chondritis is likely to be somewhat nodular, but in hema- 
toma it is quite round and regular. 

My own case, illustrative of this subject, is briefly as fol- 
lows: J. S., aged 42, in May, 1874, had a violent pain in the 
right ear, which continued for eleven days with very little 
abatement, when the membrane ruptured and the ear dis- 
charged large quantities of thick creamy pus, with but lit- 
tle relief to the pain. After one month a polypus made its 
appearance in the meatus and was removed. Subsequently 
a very painful, circumscribed swelling of the meatus was in- 
cised, which gave great relief. 

In July a swelling made its appearance in the region of 
the concha, rapidly extended to the whole of the auricle, in- 
creasing its size prodigiously. On September 1st I saw the 
patient for the first time, and found a large abscess occupy- 
ing the region of the concha and extending upon the auri- 
cle in all directions so as to involve about half of its super- 
ficial area. As the engraving will show, it pointed both in 
front and behind, causing the auricle to stand out from the 
head at right angles. In front of the meatus, near the tra- 
gus, was a circumscribed swelling, with a fistulous opening 
in its apex. The swelling of the auricle was somewhat 
nodulated, giving it the appearance of carcinoma. Fluc- 
tuation was easily detected both in front and behind, as the 
walls of the abscess were very thin. An incision, made pos- 
teriorly, evacuated about five drachms of pus. A finger 
passed into the incision revealed the fact that the cartilage 
of the auricle, in the region of the pus cavity, had entirely 
disappeared in front and behind; there was nothing left ex- 
cept integument and connective tissue. Subsequent to this, 
small abscesses made their appearance as follows : three 
were incised just above the region of the lobulus, one in 
the tragus, and two on the upper portion of the helix. The 
principal pus cavity closed in three weeks without special 
treatment. Carbolic-acid solutions were injected at first, 
but they were not well borne, and were discontinued. 
Syringing out the cavity with warm water daily was prac- 
tised. The discharge from the abscess in the helix was 
somewhat glairy in consistency. The incision in this part 
may be seen in the third cut. 



PERICHONDRITIS AURICULA. 63 

The duration of the affection was a little more than five 
months. There was no insanity, present or past, in the pa- 
tient or his family, and no history of previous traumatism 
was elicited. My opinion of the nature of this case, which 
coincided with that of Dr. Mathewson's, who previously 
had treated the patient, was that these abscesses depended 
on a perichondritis, and that this had been developed from 
an inflammation of the tympanum, which had passed out- 
ward along the meatus, and involved the auricle by exten- 
sion. 

From this case and subsequent ones, to be herewith re- 
ferred to, I shall adhere to the opinion that this affection 
is not identical with haematoma auris, although such an 
authority as Buck regards them as identical, or at least 
closely allied affections. One of the most important cases 
reported, which also strongly resembles my own, is that of 
Dr. Knapp, in the Arch. Otol., vol. ix., No. 3, p. 195 et seq., 
and is as follows: H. A., of New York, 16 years of age, 
had always enjoyed good health. On August 29, 1879, 
he had a moderately painful swelling in the right ear, of a 
few days' duration. External meatus slightly red and swol- 
len, so as to close the canal. If the auricle was drawn back- 
ward a small opening appeared in the canal; hearing good. 
On the anterior lower part of the canal fluctuation was ob- 
served. Diagnosis of furuncle was made, and the swelling 
was incised and a watery pus escaped from the opening. 
A week later the swelling of the canal diminished, but the 
lower part of the concha was red, swollen, and indistinctly 
fluctuating. After three days, the symptoms becoming 
more declared, the swelling was incised, and watery pus 
escaped. Four days later the swelling filled the concha, 
was dark red, and had a doughy feel. It was opened above 
the lobule, and a viscid fluid, containing dense yellowish 
flakes, was evacuated. A probe introduced through the 
opening could be passed more than a half-inch upward. 
The perichondrium was detached from the cartilage. A 
silver drainage-tube was introduced into the opening, and 
the ear was covered with picked lint, held in position by a 
roller bandage. The swelling crept slowly over the whole 
anterior surface of the auricle excepting the lobule. In 
some places it was diffuse, in others nodular and fluctuat- 
ing. The latter were lanced, and a material was evacuated 
similar to that before described. At the beginning of the 
sixth week the swelling had attained its height. The helix 



64 DISEASES OF THE EAR. 

was swollen, and the fossa of the helix was preserved only 
at its upper part. The remainder of the auricle, except the 
lobule, presented one uneven, nodular, reddish swelling. 
The tragus was swollen and misshapen, and in front and 
below enlarged glands were felt. The whole pinna was 
enlarged to about one and a half times its normal size. For 
some weeks the meatus was found to be moist, with a scant 
puriform discharge, which evidently came from an opening 
communicating with that of the auricle. Some granulation 
tissue was scraped out of the cavity of the auricle by means 
of a sharp spoon. After the sixth week the swelling began 
gradually to subside, the aperture leading to the abscess 
cavity closed, discharge ceased, and the auricle shrunk and 
remained irregularly corrugated, with an obliteration of its 
normal configuration, except the somewhat atrophied helix, 
which remained, only slightly changed. The pinna had 
been reduced to about two thirds its normal size. It was 
pressed against the side of the head, and was much disfig- 
ured by nodules and ridges. The lobule was unaffected. 
The process lasted ten weeks. On May 30th, 1880, the pa- 
tient was found to have a perforation in the drum-head, the 
result of an inflammatory process occurring subsequently 
to the symptoms already described, and not in the least de- 
pendent on them (so I infer). Knapp also reports a second 
case — that of a young lady aged about 17 years. There 
was no apparent cause for the trouble. Her ear looked 
exactly like the one already described during its fourth 
week. The concha was filled up, and there was distinct 
fluctuation. The patient declined treatment and disap- 
peared. He quotes a third case from Dr. R. C. Brandeis, 
of New York. The patient had a mild chronic aural ca- 
tarrh, with pronounced pharyngitis. The same reddish 
diffuse swelling developed in the cartilaginous portion of 
the meatus and the adjacent portions of the concha which 
was noted at the beginning of the first case. A large and 
deep opening was made, watery pus escaped, and the 
swelling subsided in a few weeks. 

Dr. K. also quotes Dr. R. Chimani, in the Arch. f. Ohrhk., 
vol. ii. pp. 169-171, 1867, as follows: Without assignable 
cause, the concave surface of the auricle (of a patient) be- 
came painful, red, and so much swollen that on the fourth 
day all elevations and depressions had disappeared. Poul- 
ticed it for three days, when fluctuation manifested itself 
over the whole of the swelling. A large vertical incision 



TREATMENT OF PERICHONDRITIS AURICULA. 65 

resulted in the evacuation of a synovia-like fluid mixed 
with pus. The cartilage was laid bare, and on probing, its 
integument was found detached to the whole extent of the 
concavity of the auricle. The abscess cavity was syringed 
with lukewarm water twice daily, and dressed with lint 
and cotton wadding. In twenty-four days the patient com- 
pletely recovered, without any deformity of the auricle. 
Dr. Pooley, of New York, also reports a case of perichon- 
dritis auriculae in the Tr. of Med. Soc. of the State of New 
York for 1 881, p. 212 et sea., as follows (the patient consulted 
the doctor on September 24, 1877): Mrs. G., aged 21, born 
in New York, of German parents. Three weeks pre- 
vious to consulting the doctor she had some pain and 
itching in the right ear. She said that a boil formed in 
her ear, broke, and gave exit to a greenish-looking core. 
She felt better for a time, but the ear again troubled 
her, and she sought advice. On the anterior lower wall 
of the meatus, near its outer portion, was a swelling re- 
sembling a furuncle ; on incising it, watery-looking pus 
escaped. 

October 2d, the swelling subsided, but the lower part of 
the concha was red and swollen; no distinct fluctuation. 
The swelling rapidly increased, and became tender and 
painful. There was an ill-defined sensation of fluctuation. 
In a few days the swelling had obliterated the concavity of 
the concha; it was of a dark-red color and boggy to the 
touch. An incision gave exit to a thin, glairy-looking 
fluid, mixed with yellowish-white shreds. A probe could 
be passed along the anterior surface of the auricle as far as 
the antihelix. The cartilage was roughened, hard, and 
could easily be detached and raised, together with the skin, 
by means of a probe. A tent of charpie was introduced 
into the wound, the ear covered with absorbent cotton, and 
a flannel roller bandage was applied with pretty firm pres- 
sure. The swelling slowly extended to the whole of the 
front of the auricle except the lobule. This swelling was 
in some places diffuse and in others nodular, the whole 
being of a diffusely red color and painful to the touch. 
Two abscesses were formed — one in front of the lobule and 
the other behind — which were opened (probably suppurat- 
ing glands). A probe passed into the fistulous opening, 
which remained for some time in the anterior incision, 
could be pushed into the concha and along the anterior 
surface of the auricle until its point could be felt under- 



66 DISEASES OF THE EAR. 

neath the upper margin of the helix. The acute inflamma- 
tory symptoms lasted for about two months, accompanied 
by considerable pain, which was aggravated at night. Nar- 
cotics were often required for its relief. In consequence of 
her suffering she lost flesh, and became nervous and irri- 
table. 

Eleven incisions were made in the auricle wherever points 
of fluctuation were discovered. Carbolic-acid solutions, 
and afterwards solutions of iodine, were injected into the 
abscess cavities. The compressive bandage was kept quite 
constantly applied: it seemed to allay the pain. Remedies 
for supporting the strength were used. There was no dis- 
charge at any time from the meatus. The membrana was 
normal and the hearing was but little affected. The case 
was under treatment until March 27, 1879. The tragus 
assumed nearly a normal appearance; but the calibre of 
the meatus was diminished from permanent thickening 
and enlargement of its cartilage; the deformed concha also 
pushed forward and encroached on its calibre. The entire 
auricle, except the lobule, had participated in the deform- 
ity, and was slightly diminished in size. January 18, 
1881, the hearing is found normal; no change in the de- 
formity, but the ear "sweats more or less all the while, and 
in all temperatures," according to the patient's own state- 
ment. Dr. P. quotes from Dr. Born, who showed him a 
case in which the disease seemed to be developing from an 
external otitis and affecting the lower part of the concha, 
as in his own case. He holds the opinion that this affec- 
tion should not be confounded with hematoma auris. He 
regrets having made so many incisions, as " they were fol- 
lowed by no relief to the pain, nor did they in any way 
hasten the cure;" but he admits that it may be well to make 
one incision into the most dependent part of the swelling to 
gain access to the abscess cavity. Dr. Kipp, of Newark, 
reports in the Tr. Am. OtoL Soc. for 1873, p. 79, a case of 
what he designates as spurious othematoma, the result of 
a burn. A boy, aged 5, was brought to the Infirmary on 
account of a painful swelling of his ears. Four weeks pre- 
vious his face and ears were burned by an explosion of gun- 
powder. Two weeks later appeared the swelling of the 
ears. The auricles were pushed out from the head, and 
the upper two thirds were pear-shaped. Auricles hot, and 
sensitive to the touch; surfaces of the swellings convex and 
mooth; skin of normal color, but looking as though it had 



TREATMENT OF PERICHONDRITIS AURICULA. 6? 

been blistered ; fluctuation in both. Incision gave exit to 
a yellowish glairy fluid. The swellings did not collapse. 
In both was found a cavity the size of a hickory nut, lined 
by a smooth, shining membrane. The anterior wall of 
both cavities was about a line in thickness, and apparently 
composed of thickened perichondrium ; the posterior wall 
was formed of cartilage. Tincture of iodine was applied 
to the interior and exterior of the swelling, and in two 
months recovery took place, without deformity, except a 
wrinkled condition of the walls of the fossa helicis. He 
remarks that not a single case like this is recorded ; but 
that spurious othematoma, the result of contusion of the 
auricle, with or without fracture, are not unfrequently ob- 
served. 

Pathogenesis. — Already a number of cases are on record 
where inflammation of the tympanum has first extended to 
the cartilage of the meatus externus and thence to the car- 
tilage of the pinna. An otitis externa, with inflammation 
of the cartilage of the meatus, has also involved the auricle 
by extension. Again, a few cases have been recorded where 
the perichondritis has commenced in the auricle, generally 
in the concha, by a minute spot, where the cartilage seems 
to have undergone softening, by some process of degenera- 
tion not precisely understood ; it would, however, seem to 
be dependent on some disturbance in the nutrition of the 
part. A great variety of injuries to the auricle, where the 
cartilage has sustained violence, is sufficient to provoke the 
disease. The statues of some of the renowned athletes in 
olden times exhibit deformed auricles, undoubtedly the re- 
sult of violence received in boxing encounters, and the 
perichondritis resulting therefrom. The sword practice of 
the German university students in duelling often results 
in perichondritis auriculae, the ears seeming to be a favor- 
ite point of attack. Burns of the auricle (see Kipp's 
case) or frost-bites (Troltsch's case, where a patient rested 
the auricle against a window-pane, to which it froze) 
will develop this disease. Simple exposure of the auricle 
to cold is often a sufficient provocation for the disease. 
A furuncular inflammation of the auricle in subjects 
lacking a normal amount of energy may lead to the de- 
velopment of a perichondritis. The causes which lead 
to the development of perichondritis in hematoma are con- 
sidered under the head of the latter. [The following case 
may throw some light upon the pathogenesis of a form of in- 



68 DISEASES OF THE EAR. 

flammation ot the cartilage and its perichondrium, which is 
believed to be well-nigh unique :] 

Chondritis and Perichondritis of the Auricle, Probably of 
Neuro- Paralytic Origin. 

F. K., aged forty-six, applied to the Manhattan Eye and Ear 
Hospital on October 27, 1884. About two weeks since he 
noticed a small pimple situated near the center of the auricle 
in front. This soon gave rise to a watery discharge. After 
four days the ear began to swell, until every part of the 
auricle, except the lobulus, was swollen to nearly twice its 
normal size. A considerable portion of the cheek adjoining 
the auricle was also swollen, red, and numb. A carbolic acid 
lotion soon relieved this swollen condition. The auricle and 
the adjacent regions are completely anaesthetic, although this was 
at first only partial. On the date of application the auricle is 
much swollen, except the lobulus ; red, moist, and with a scurfy 
state of the epidermis, the appearance resembling that of acute 
eczema. This scaly material may be removed easily, leaving 
sound, somewhat reddened skin beneath, except in some of the 
deeper depressions of the auricle, notably the fossa scaphoidea. 
The lesion described by the patient as a pimple, located just 
behind the concha and within the helix, now presents the 
appearance of a dark-brown crust, which also appears on the 
posterior surface of the auricle, opposite to the scab in front, 
as. a livid spot. 

On applying a probe, it is easily thrust quite through the 
auricle, emerging on its posterior aspect, and showing a com- 
plete destruction of all the tissues of the auricle. This was 
accomplished without sensation to the patient. A sero-san- 
guinolent and somewhat glairy discharge proceeds from this 
opening. The patient denies syphilis ; his voice is like that of 
a child or a woman. The cause of this is found by Dr. Douglas 
to be dependent on a paralysis of the left vocal cord ; this 
trouble dates back six years. Has some vertigo. A one-per- 
cent, solution of acid, carbol. was ordered, with which to bathe 
the auricle freely. 

October 31st : the loss of tissue posteriorly is so far restored 
as to be nearly healed, the reparative material having filled up 
the ulcerated place so as to present only a shallow ulcer in 
front. This is covered by an adhering, yellow-looking scab ; 
signs of reparative action everywhere manifest. The spot in 
the scaphoid fossa is still covered with a yellowish scurfy 
material, but, on removal, the skin beneath is perfectly sound. 



THE DIAGNOSIS OF PERICHONDRITIS AURICULA. 69 

Two days afterward, however, on removal of the scurfy 
material from this part, the skin beneath was found to be ulcer- 
ated. This had now begun to resemble the other and principal 
ulceration. This yellowish scurfy material still covers other 
parts of the auricle more like the appearance at first, only the 
auricle is much less swollen. On November 3d the ulcer in 
the scaphoid fossa has healed, leaving a small yellowish scab, 
easily removed ; the principal lesion has nearly healed ; pos- 
teriorly, the aperture has nearly closed, being covered in mostly 
by sound skin. This has progressed steadily until November 
20th, when the aperture behind is completely closed, and in 
front it has nearly healed ; swelling of the auricle entirely dis- 
appeared ; no return of sensation to the part. December 1st, 
auricle nearly restored to its normal condition, but ulceration 
seems to have commenced again at the original seat. Behind 
the ulcerated place the parts are somewhat livid, as though the 
old condition was about to return. The ulcer was touched 
with a fifteen-per-cent. solution of carbolic acid several times, 
at intervals of two days, and the auricle has been bathed several 
times a day in a solution of bichloride of mercury, one-twelfth 
of a grain to the ounce of water. January 2d, 1885, auricle 
completely healed, except that just above the old ulceration 
there is a minute bloody bleb, which was easily ruptured. The 
upper and anterior portions of the auricle still exhibit a some- 
what scurfy condition. In addition to the treatment already 
spoken of, iodide of potassium was given, and the galvanic 
brush was applied to the anaesthetic parts ; ergot was also ad- 
ministered. There has been no restoration of the paralysis of 
the vocal cord, nor of the anaesthesia. The patient has been 
seen some months after the difficulty has subsided, and there is 
no relapse. 

The case seems to me unique, and quite analogous to the 
neuro-paralytic affections of the cornea. It is not quite de- 
scriptive to call the affection perichondritis and chondritis, as 
there was added to this an affection of the skin covering the 
front of the auricle which I never have seen in any true case 
of perichondritis or chondritis of the auricle. 

Dr. Seguin thought that the ear affection was the result of 
mild traumatism, induced, possibly, by scratching the part, 
together with the subsequent sepsis. He thinks the ear would 
have remained sound if protected from injury and bacteria, the 
state of anaesthesia not offering the usual protection from 
traumatism existing in the normal condition. 

The diagnosis is mainly from haematoma auris. The 



70 DISEASES OF THE EAR. 

latter affection is essentially a bloody tumor of the ear. As 
far as I have observed, no case of perichondritis has ex- 
hibited the symptom of blood effusion. It is true that the 
discharge from an abscess in perichondritis is often tinged 
with blood, but it never is pure blood or a blood-clot. The 
onset of the two diseases is also quite different; the collec- 
tion in haematoma appears much sooner than in perichon- 
dritis, or sooner than pus is capable of forming in conse- 
quence of inflammation. It is not denied that later on a 
haematoma may result in a perichondritis, consequent on 
the presence of the blood effusion, but this does not place 
it in the same category. 

There seems also no question but that a haematoma may 
run its course without resulting in a perichondritis. The 
swelling in haematoma is even, rounded, and utterly devoid 
of the irregular nodulations seen in perichondritis. As the 
lobule is unaffected in both haematoma and perichondritis, 
this fact is not of value in differentiating between these 
affections, but it does suffice to separate diffuse inflamma- 
tion of the auricle from inflammation of its cartilage, as in 
the former the lobule is as readily attacked as the other 
portions of the ear. 

The color of a haematoma is usually a darker red than 
that seen in perichondritis. In haematoma from injury the 
difference is not so well marked; indeed, in many instances 
it is as easy to make the diagnosis of perichondritis as of 
haematoma. If the injury has resulted in hemorrhage only, 
we may place it in one category; and, on the other hand, if the 
cartilage has received considerable injury there will be an 
inflammation of that tissue. The term " Spurious Othema- 
toma," used by many writers of distinction, indicates that 
there has been embarrassment in making an exact diagnosis. 

So far, no insane people have been observed with peri- 
chondritis from the outset. In the latter disease only one 
ear seems to be affected, while in the former the fellow ear 
may occasionally be involved; but usually this occurs sub- 
sequently to the attack on the first ear. Haematoma is not 
as painful as perichondritis. The febrile symptoms are 
much more prominent in perichondritis. Dr. Roosa (Text- 
book), p. 113, says: "Any inflammation of the integument, 
connective tissue, and cartilage of the auricle, leading to the 
effusion of serum, blood, or the formation of pus, will be 
apt to cause a deformity of the part; but such a case should 
be distinguished from an othematoma." This shows that 



DIAGNOSIS OF PERICHONDRITIS AURICULA. 71 

as long ago as 1873 Dr. Roosa had doubts about placing all 
tumors of a character similar to othematoma in that cate- 
gory. He appends a cut representing " an auricle deformed 
by inflammation," showing a perfect lobulus, however, 
where an inflammation of the cartilage of the meatus had 
extended to the tissues of the auricle (I suppose including 
the cartilage). Dr. Pooley (loc. cit.) speaks of a symptom 
of perichondritis not mentioned by other authors, namely, a 
disposition of the auricle after a perichondritis to perspire 
much of the time, whether the temperature be high or low. 
This is not mentioned in any reported case of othematoma, 
as far as I know. 

The prognosis as to the hearing is, I believe, always favorable. 
In the earlier stages the hearing may be lowered from 
swelling of the walls of the meatus or of the concha, which 
may encroach on the calibre of the meatus. The principal 
lesion in this affection is the distortion of the auricle, due 
to inflammatory changes in its cartilage. I believe my own 
case shows these changes as thoroughly as any I have heard 
of, the cartilage over a large area of the auricle being en- 
tirely destroyed by suppuration. When the cartilage is not 
destroyed, it sometimes takes on a proliferative action, and 
increases in size, becomes irregularly thickened and greatly 
distorted. The concha and its neighborhood is likely to 
suffer most, while the helix may often be unchanged. A 
few cases recover by resolution, without any distortion of 
the auricle whatever. If any considerable change has taken 
place in the shape of the auricle, it will also be diminished 
in size. 

Treatment. — The cases herewith reported give valuable 
hints as to treatment. This being a disease of which little 
has been known until recently, there is still wanting a suffi- 
cient amount of experience to meet all the indications for 
treatment successfully. Inflammation of cartilaginous 
structures seems not to be as well understood as that of 
other tissues. In the earlier stages of the disease when the 
parts are swollen, hot, and tender, it is well enough to try 
the effect of cold applications, having previously stopped the 
meatus with cotton so as to prevent harm to the tympanum 
from the effects of the cold. A bladder or rubber bag filled 
with cold or iced water maybe applied to the parts. Some- 
times this will cause pain: then it will be well to reverse 
the temperature of the water, making it warm, and so regu- 
lating its temperature as to make it agreeable to the pa- 
5 



72 DISEASES OF THE EAR. 

tient. We have in mind, however, the tendency of the car-, 
tilage to soften and break down with purulent formations, 
which may be encouraged by an excessive use of the warm 
applications. The irritation of the inflamed surface may 
be diminished by lead and opium washes, or even painting 
upon the part tincture of iodine. Sometimes the warm ap- 
plications may be applied best by gently bathing the part. 
Early in the treatment it may be necessary to administer 
opiates internally or inject morphine hypodermically, for 
the prolonged sufferings of the patient may depress the 
vital energies to a considerable desrree. 

There are diverse opinions about the propriety of in- 
cisions. If the evidence of fluctuation is decided, and there 
appears to be a pus cavity of considerable size, there can be 
little doubt about the propriety of making a free incision. 
If, on the contrary, the fluctuation is obscure and attended 
by a boggy or doughy sensation imparted to the touch, and 
the suspected spot is not of large area, it is better not to 
use the knife. On this point, however, there are conflicting 
opinions. Sometimes it seems to do good to open these 
places, and again it accomplishes nothing. The affection 
often disappoints expectations, and seems to follow a law of 
its own, in its progress towards recovery. 

After the incision has been made, some sort of a compress 
is needed, as the abscess cavity shows little disposition to 
close in consequence of the inelasticity of its walls; more- 
over, the compress often gives relief from pain. A tent of 
charpie may be used to keep the wound open, or, if the pa- 
tient can be seen often enough, it is better to pass in a 
probe as frequently as the incision narrows or closes, and 
break up any adhesions which may have formed. This in- 
dication may also be met by the use of a drainage tube. I 
prefer one of soft rubber. In some instances the cases seem 
to do better if the abscess cavity is injected with tepid 
water only, and in others tincture of iodine injected in full 
strength or diluted does well. Carbolic acid, one drachm 
to the pint of water, or a ten to twenty gr. sol. of arg. nit. 
may do good service used as injections. If these seem 
to irritate, increase the pain, and add to the swelling, 
thev should be diluted or even discontinued. Occasional- 
ly granulations may form within the abscess cavity; they 
may be removed by means of forceps, curette, or sharp 
spoon. In such cases nitrate-of-silver injections will very 



TREATMENT OF PERICHONDRITIS AURICULA. 73 

properly follow, or the caustic may be introduced on a 
piece of cotton in strong solution, to destroy any remains 
of the granulations. 

In using the roller bandage for a compress, flannel will 
be found more elastic than muslin or linen, and may be 
preferred. A piece of cotton may be placed behind the 
auricle, and another in front; the piece covering an incision 
may be carbolized, and should be changed frequently to 
prevent the discharge from irritating the auricle. The 
roller may be passed over the top of the head and beneath 
the chin. After the acute stage has passed, I know of no 
better application to the auricle than tr. of iodine, applied 
at first twice a day, and after the parts become sensitive 
once every two or three days. Occasionally the oxide of 
zinc ointment will do good service, or even plain vaseline. 
Sometimes, however, greasy applications irritate. The 
auricle should always be protected from the cold. As the 
canal sometimes shows a tendency to narrow, it may be 
well in the absence of pain or inflammation to introduce a 
sponge-tent to resist this tendency. 

Inasmuch as the affection is often tedious, and the patient 
may become depressed by the pain and the consequent dis- 
turbance to nutrition, it will be well in the outset to en- 
deavor to resist this tendency by the careful regulation of 
the nutrition of the patient, attending to the stomach and 
bowels, not forgetting that the pain may depend in part 
upon general depression, when it will be better relieved by 
brandy than morphine in many instances. A variety of 
tonics will naturally be suggested, at the head of which 
stand bark and iron. 



INJURIES OF THE AURICLE. 

These for the most part belong to the domain of general 
surgery. The auricle may be braised, frost-bitten, incised, 
its cartilage fractured, the lobulus divided into two equal 
portions by the cutting out of an ear-ring, etc. In any surgi- 
cal operation for the repair of a damaged auricle from 
traumatism, it is well to remember that the cartilage is of 
low vitality, heals languidly, and does not bear the inser- 
tion of sutures well. The woodcut (Fig. 23) represents an 
auricle on which I performed the following operation : 



74 DISEASES OF THE EAR. 

burning, smarting pain. There is also a tendency of any in- 
flammation of the auricle to extend to the perichondrium, and 
result in untoward complications. The auricle suffers more 
than many other parts from traumatism. The following case 
may illustrate some of the points under discussion : Joseph 
Gahan, aet. 15, has had symptoms of a subacute middle ear 
trouble for two or three weeks. On March 3d, 1884, he pre- 
sented himself for treatment, having been violently struck on 
the ear by a piece of coal, which had been thrown by an un- 
seen hand. The region of the antitragus and concha, extending 
to the antihelix was much swollen. There was swelling in the 
mastoid region, the ear standing out somewhat from the side 
of the head. There was considerable redness. The swelling 
pits slightly on pressure. The meatus was so swollen that 
only a small speculum could be inserted, which caused con- 
siderable pain. At its infero-post aspect was some laceration. 
Ordered to bathe the part with lukewarm water every two 
hours. March ioth : patient returns nearly well ; little swell- 
ing remains, and there is slight tenderness in the region of the 
tragus ; meatus nearly restored to its normal calibre. 

I have seen the auricle broken or cut into several portions, 
the parts, however, being more or less intact, although the 
auricle was misshapen. In closing these wounds, sutures must 
be used, as a rule, avoiding the cartilage. It will often be 
necessary to place the sutures in front and behind the auricle, 
especially if they only penetrate skin. Coaptating the edges 
of the wound will not always be sufficient, as the organ may 
still require to be shaped. This may be done in a variety of 
ways ; a piece of cork may be made of such a shape as to press 
the auricle into position. This should be applied in front, ( 
while a piece of cotton may support the part from behind, 
giving the auricle the proper inclination with the head ; the 
whole to be kept in position by an appropriate bandage. If 
the surgeon has considerable ingenuity, a plaster of Paris sup- 
port may be made, moulding the moist mass into the shape 
the ear ought to assume. A little vaseline applied to the 
auricle previous to the adjustment of the " splint " will prevent 
the latter from adhering to the part inconveniently. 

Even then the success may not be equal to the absolute 
restoration of a perfect looking auricle, as the closure of the 
cartilaginous portions is usually accomplished only by the in- 
terposition of fibrous tissue (see Fig. and the case reported), 
preventing the perfect shaping of the parts, due to the yielding 
of the coaptating portions. 






TREATMENT OF PERICHONDRITIS AURICULA. 75 

The tendency of the auricle to heal when wounded is very- 
strong. According to Troltsch, the auricle, when completely 
severed from the head, has been known to become reattached 
by careful coaptation of the parts by means of sutures and 
proper support. 

Blows on the auricle may cause an extravasation of blood, 
resulting in the formation of a considerable rounded tumor of a 
darkish color, much resembling othsematomata, which, indeed, 
is asserted to be the cause of these tumors by many authorities. 
Another case recently under observation, where a wooden mallet 
struck the side of the head, including the auricle, caused the lat- 
ter to swell considerably, become red, excessively tender to the 
touch, and accompanied by a smarting, burning pain, further 
illustrates this subject. It also rendered the patient quite hard 
of hearing for a few days, this being accompanied by weakened 
bone conduction, evidently from concussion to the nerve 
within the labyrinth, or possibly minute haemorrhages, but like 
some cases of boilermakers' deafness, to which it seemed 
analogous, it has spontaneously recovered in a few weeks. 

ABSCESSES ON THE LOBULUS. 

It is a matter of common observation that at the point where 
the lobulus is punctured for the ear pendant, a small, hard por- 
tion of proliferated connective tissue may be felt by compres- 
sing the part between the thumb and fingers. This sometimes 
takes on a suppurative form of inflammation, and a consider- 
able abscess results. I have recently seen such a case, where 
the lobulus was at least three times the normal size ; was very 
red and painful, and contained pus. Evacuation of this by a 
small puncture was performed. The puncture should generally 
be made at the aperture in which the earring has been worn. 

Ear pendants sometimes cut their way out of the lobulus on 
account of too great weight, or by reason of being inserted too 
near the lower border, or from being violently pulled upon, 
causing it to be separated into two portions, and resulting in a 
somewhat unsightly deformity. This is easily remedied by re- 
freshing the edges and coaptating the parts with sutures. In 
any surgical operation for the repair of a damaged auricle from 
traumatism, it is well to remember that the cartilage is of low 
vitality, heals languidly, and does not bear the insertion of 
sutures well. The woodcut (Fig. 23) represents an auricle on 
which I performed the following operation : 



7 6 



DISEASES OF THE EAR. 




It was in the case of a child who 
some years before had had a peri- 
ostitis of the mastoid, destroying 
the external table. This ulceration 
also extended to the posterior 
aspect of the auricle, and de- 
stroyed by ulceration so much of 
its cartilage as to produce a large 
gap, dividing the auricle into an 
upper and lower portion. I 
pared the edges of the auricle 
at these points, and brought 
them together by sutures intro- 
duced into the skin only. The 
engraving shows the somewhat 
imperfect union of the parts, and 
also the cicatrix over the mas- 
toid. Under the heading of 
Perichondritis Auriculae is de- 
tailed the effect of burns upon the 
auricle. 



Fig. 23.— Results of an Operation on 
the Auricle. 



CONGENITAL MALFORMATIONS OF THE AURICLE AND OTHER 
PORTIONS OF THE ORGAN OF HEARING. 

The auricle may be completely or partially enlarged in size, 
but this is exceedingly infrequent, the opposite condition, 
microtia, being much more likely to occur, the deformities show- 
ing a general tendency to arrest of development rather than 
the opposite condition. The different varieties of microtia are 
almbst without limit. I have seen one or two rounded nodules 
with or without cartilaginous development representing a rudi- 
mentary effort at the construction of an auricle, but without the 
slightest resemblance to one. The auricle may be perfect in shape 
except in the arrest of development of one of its parts, as of 
the lobules, the helix, the antihelix, the concha, etc. Again, it 
may be divided into two or more unequal parts. Polyotia 
is another form of malformation, in which auricles, either per- 
fectly formed or only rudimentary, may be scattered about in 
the neighborhood of the head and neck, being found in the 
cheek, neck, shoulder, etc. In a certain number of cases entire 
absetice of the auricle may be noted, but in a given case, where 
this is suspected, the touch may reveal beneath the skin traces 



CONGENITAL MALFORMATIONS OF THE AURICLE. 77 

of cartilage, which hint at an attempt towards the formation of 
an auricle. The auricle may sometimes be placed wrong side up, 
or with the posterior edge in front, besides other malinsertions. 
Occasionally it stands out from the side of the head almost or 
quite at right angles, presenting an unsightly deformity, as in 
Ely's case. 

The case on which I operated, and am about to describe, is 
a somewhat rare form of deformity. Sometimes the auricle 
appears pressed together from above downwards — "cat's ear," 
as seen in old statues of Pan. The tragus may be so turned 
inwards as to close the meatus. The lobule is frequently ad- 
herent to the skin. Sometimes the upper part of the auricle 
is quite pointed (much like the case I operated on, after being 
brought into position), as is constantly seen in old statues of 
Satyrs and Centaurs, and which Darwin regarded as character- 
istic of the earlier orders of human beings. The fistula auris 
congenita is found in a large number of these cases, and is a 
part of the general arrest of development, being a remnant of 
the first branchial cleft. The fistulous opening lies generally 
in front of the auricle, but sometimes within its area. 

I saw a case a few days since where there were no less than 
four of these openings, scattered about different parts of the 
deformed auricle. From these openings a whitish yellow 
cream-like fluid exudes, containing numerous pus cells. It is 
not easy to trace them to deeper parts of the ear. Cicatricial 
depressions are often seen in the region of the deformed 
auricle, and seem also to be anomalies in the closure of the 
first branchial cleft. The meatus externus is frequently closed 
by a thin septum of soft parts, or it may be altogether absent. 
Sometimes it is closed by bone or cartilage. The Eustachian 
tube and tympanum are nearly always present, although they, 
as well as the labyrinth, may be totally undeveloped. In very 
rare instances two petrous portions to each temporal bone 
(Cassebohn) have been observed. Associated with these de- 
formities, there may occasionally be found evidences of faulty 
development elsewhere, although this is somewhat exceptional. 
The entire temporal and malar region was much flattened in 
one case of deformed auricle. Another case had a fissure-like 
prolongation of the mouth downward and backward into the 
left cheek, involving all its structures ; the external meatus was 
larger outwardly, and placed more anteriorly than usual. Cleft 
palate somewhat frequently accompanies deformity of the 
auricle. Abnormal position of the lower maxilla has been 
observed. Deformities in both auricles of a given patient seem 



78 DISEASES OF THE EAR. 

somewhat more frequent than in one alone. Arrested develop- 
ment in the first branchial fissure seems to be the cause of 
these deformities. The hearing is generally lowered in these 
cases, but never totally abolished, unless in those rare instances 
of arrested development of the labyrinth. As to what may be 
done to benefit these cases : In closure of the meatus by soft 
parts, if not extending too deeply, relief may be obtained by 
opening the meatus, this being maintained by sponge tents, 
bougies, etc. Some patients may have the hearing improved by 
inflation of the tympanum, even in closure of the meatus, when 
the inflation sounds may often be heard. In Operating for the 
Defon?ied Auricle, the ingenuity of the surgeon may be greatly 
taxed. A shrunken and insufficient auricle may be supple- 
mented by a flap from the cheek, temple, or neck. Often it is 
as well to remove an auricle entire, if it is too much deformed 
and cannot be corrected. 

As far as my observation and experience goes, the cartilage 
of the auricle may be operated upon with the confident hope 
that reparative action is likely to result. It may be well 
enough not to introduce more sutures in it than necessary, 
passing them into the integument rather than the cartilage. 

The following case illustrates the subject so well, that it 
is given with considerable fulness : F. E. W., Jr., set. 16, had 
a congenital malformation of the left auricle ; signs of arrested 
development on left side of the chest ; face unsymmetrical. 
This auricle was placed a half inch lower than its fellow, 
and was somewhat smaller. The upper and anterior portion 
of the helix was placed in front of the tragus, resulting in a 
doubling up of the auricle somewhat in an antero-post direction. 
The meatus was partially covered by the auricle, and natur- 
ally, diminished the hearing. The patient, not being strong, 
and having a mitral regurgitant murmur, ether was adminis- 
tered somewhat sparingly, not bringing the patient absolutely 
under its influence, but sufficiently for the purpose. 

An incision was made, separating the auricle completely 
from its faulty attachment, which extended nearly half its 
length. At the termination of -this incision a second incision 
was made, one inch and a quarter in length, directly upward in the 
line of what the corrected position of the auricle should occupy. 
By undermining the skin on either side of this incision an opening 
was made sufficiently wide to insert the cut surface of the 
auricle. In order that it should be applied to the part with 
the proper inclination, the upper or posterior border was 
moderately pared. It was now accurately fitted into its new posi- 



CONGENITAL MALFORMATIONS OF THE AURICLE. 79 

tion, giving the auricle a very natural appearance. It was 
fastened by twenty silk sutures. These were placed only 
in the anterior edge of the wound, as the parts were then 
found perfectly coaptated. At the summit of the auricle two 
sutures were inserted, fastening it to the side of the head, one 
of which was placed in the posterior border of the incision ; 
this caused the upper part of the auricle to adhere to the side 
of the head, instead of standing out free as in nature. This 
seemed necessary to preserve the vitality of the part. In front 
of the meatus and somewhat below was a slightly raised car- 
tilaginous development, perhaps a rudimentary concha. The 





Side View of Deformed Auricle. 



Auricle after Operation. 



skin was dissected from this, but not detached, the cartilage 
pared to the level of the surrounding parts, when it was re- 
covered by the integument previously removed. The place 
from which the auricle was separated was covered by drawing 
together the skin on either side by sutures. Carbolic acid 
solution was used freely during and after the operation. A 
compress of cotton wool and a roller bandage supported the 
auricle in its new position. In two days the wound in the 
lower portion had completely united ; upper part of auricle 



80 DISEASES OF THE EAR. 

reddened and moderately swollen. In four days all the sutures 
except three at the upper portion were removed ; healing per- 
fect. In two days more the remaining sutures were removed, 
together with the bandage, when the whole of the wound was 
found perfectly united. The two sutures in the upper part of 
the auricle were passed through cartilage, and more reaction 
was noticed than in the other sutures, which were passed 
into the skin. The patient is satisfied with the operation. 
The subjoined woodcuts show the auricles before and after 
operation. Dr. Edward T. Ely, in the Archiv. Otol., vol. 
iv., p. 97, et seq., reports an operation for prominent auricles. 
These stood out from the side of the head nearly at right 
angles, and presented a very unsightly appearance. In the 
operation on the right ear, " an incision was made through the 
skin, along the entire length of the furrow formed by the junc- 
tion of the auricle with the side of the head posteriorly. This 
was joined at each end by a curved incision carried over the 
posterior surface of the auricle, and the skin and sub-cutaneous 
tissue included by these incisions were dissected off." Car- 
tilage somewhat narrower than this, measuring i}i inches 
by i^ inches, was also removed — closed by sutures ; seven 
of these were passed through skin only, while three were 
inserted in both skin and cartilage. A small gap in the 
anterior aspect of the auricle healed by granulation. The 
sutures were removed on the fourth day ; healed kindly. 
A bandage was used, I suppose, to support the auricle in 
the corrected position. The other auricle was operated upon 
by first removing skin and cartilage together, the knife 
transfixing the auricle, and a sufficient amount of additional skin 
was subsequently removed. The first operation was preferred. 

DISEASES OF THE EXTERNAL AUDITORY 
CANAL. 

FOREIGN BODIES IN THE MEATUS AUDITORIUS EXTERNUS 
AND TYMPANIC CAVITY. 

Children have a strong propensity to thrust various 
foreign substances into their ears. Among these may 
be enumerated beans, Indian corn, peas, bits of chewing 
gum, buttons of various kinds, beads, sealing-wax, slate- 
pencils, nails, pebbles, gravel stones, pins, needles, shells, 
seeds of grain, pieces of glass, coffee beans, pieces of paper, 
fruit stones, shot, and a variety of other objects. 



FOREIGN BODIES IN THE MEATUS AND TYMPANUM. 8 1 

For the purpose of relieving pain in or about the ear vari- 
ous articles are thrust into the meatus, such as bits of cam- 
phor, cotton wool soaked in some form of anodyne, bits of 
tobacco, core of an onion, etc. Many objects are likely to get 
into the ear without the agency of the patient or his friends,as 
flies of various kinds ; and if the ear contain any foreign sub- 
stance favorable to the hatching of their eggs, the larvae may 
subsequently be found in the ear acting as irritating and even 
painful foreign bodies. The cockroach, the earwig, bed- 
bugs, or any other small animal that creeps or flies, may get 
into the ears. Sequestra of carious portions of the osseous 
meatus sometimes act as foreign bodies in the ear. A ca- 
rious third molar tooth is reported by Politzer as resting 
within the meatus for forty years. Hairs are sometimes 
found doubled upon themselves within the meatus, and 
causing considerable irritation. Dr. R. F. Weir, of New 
York, reported a case where a hair growing from the tragus 
had passed inward, rested upon the membrana, and caused 
considerable irritation. 

Foreign bodies are not by any means always likely to 
cause mischief in the meatus if they are not meddled with 
by injudicious and unsuccessful efforts at removal. Dr. 
Ludwig Mayer — Monatsch. f. Ohrenheilk., Jahr. iv. No. i 
(Burnett's reference) — reported a case where a foreign body 
remained in the meatus for over sixty years without ap- 
parently doing serious harm. Where the foreign body is 
of such a nature as to swell, in consequence of imbibing 
moisture, it is likely to do harm. If the edges of the for- 
eign body are sharp or abrupt, like a piece of rough stone, 
a bit of broken glass, a nail, a shell with sharp edges, or the 
like, there may be an inflammation occasioned even when 
it is not interfered with. In the larvae of the muscidia sar- 
cophaga and the muscidia lucilia, as described by Blake, 
— Arch. Ophth. and Otol., vol. ii. No. 2 (Roosa's reference), 
the apparatus by which the grub attaches itself to the part 
is composed of a delicate framework of horny consistency, 
from which spring two hooks having the same struc- 
ture as the framework. By means of these the larva bur- 
rows its way into the tissue on which it feeds, by alternately 
piercing and tearing. This results in agonizing pain and 
excites inflammation. 

By far the most frequent cause of trouble from foreign 
bodies is the injudicious interference by ill-advised attempts 
at removal. As a rule the foreign body will be found not 



82 DISEASES OF THE EAR. 

pushed beyond the middle, contracted portion of the 
canal, unless something has been done with a view to its 
removal. 

In that case it may be pushed down to the membrana, 
and often through it, so that it rests within the tympanum 
itself. Some years since I had a little patient with a small 
pebble in the ear. Several attempts had been made to re- 
move it, causing great pain. When I saw the child I found 
the stone crowded through the membrana and lying im- 
pacted in the inner tympanic wall. The results of attempts 
to remove a foreign body by forceps, spoons, hooks, etc., 
are sometimes surprisingly disappointing. From the nature 
of things it is apparent that any essay to remove in this 
manner tends to push the obstruction further in. I once 
attempted to dislodge a brass-headed nail from the meatus 
by instruments. The head of the nail was considerably 
wider than the meatus; it was only half-way down the 
canal, and I felt sure that all that was necessary was to 
catch it with a forceps; it was in plain sight, but on at- 
tempting to withdraw it I somehow failed to catch it prop- 
erly, and each effort drove it further in, causing consider- 
able pain to the patient. I then resorted to syringing, 
and to my great surprise it came out without any trouble 
whatever, and with little pain. I would like to formulate 
the following proposition : If the foreign body has not bee?i 
disturbed in its position by efforts to remove it, the syringe is near- 
ly always the most painless, the least violent ^ and most effective 
and safe means of removal. This proposition holds good 
without excluding those cases where the foreign body is 
swollen, or has sharp edges, like pieces of glass, or nails, or 
having the form of slate-pencils. It is simply surprising 
what power there is in a stream of water thrown into the 
ear for forcing out foreign bodies. The choice of a syringe 
is of great importance. There is little difference in the 
power of a Davidson soft rubber syringe and a good valve 
syringe. One point is of very great importance — to have 
the nozzle long, narrow, and provided with an aperture 
sufficiently small to throw a stream of the highest possible 
intensity. The syringe I have elsewhere described (see 
index) fulfils these indications, and the same kind of a nozzle 
on a Davidson syringe will do nearly as well. If no instru- 
ment-maker is near, a tip may be improvised for the David- 
son syringe by drawing a glass mint-julep tube to a narrow 
point in a flame. 



FOREIGN BODIES IN THE MEATUS. 83 

In removing a foreign body by means of the syringe the auri- 
cle should be grasped firmly and pulled upward, outward, 
and backward, so as to straighten the canal. Throw in a 
stream of pretty warm water, being careful to direct it on 
the outer edges of the obstruction. The nozzle of the 
syringe should approach very near to the object to be re- 
moved, and in some cases where the canal is swollen so as 
to somewhat envelop the foreign body the nozzle may 
even be gently insinuated at the side of the obstruction so 
as to be sure to allow the stream of water to pass behind 
it. Alternately, every side of the obstruction may be ap- 
proached if necessary. When there is no doubt of there 
being something lodged in the ear, considerable force may 
safely be used. By attending carefully to these details there 
is not often any need to resort to other methods. I have 
not used such means for removing foreign bodies from the 
ear more than twice in a year. I am sure there is a great 
mistake made in using instruments for the removal of for- 
eign bodies from the ear to the extent to which many 
surgeons of undoubted ability resort. 

As a matter of simple justice to so high an authority as 



6.TIEMANN&C0- 

Fig. 24. 
Gross' curette for the removal of foreign bodies from the ear. 

Zaufal, I would state that in his clinique, during 1880, he 
had twenty cases of foreign bodies in the ear, thirteen of 
which w T ere removed by syringing and seven by instru- 
ments. (Review in the Am. Jour. OtoL, 1882, No. 1.) Low- 
enberg, in the Berlin Med. Woch., No. 9, 1872 (Blake's 
reference), relates that he extracted a foreign body from the 
meatus, which had resisted other efforts, by dipping a brush 
into joiner's glue, passing it in and allowing it to become ad- 
herent to the foreign body. After thoroughly drying, the 
obstruction was removed by using traction on the brush 
(some older authority, I have since found, has, however, 
used this method). Where the foreign body becomes im- 
pacted from any cause whatever, it may be necessary to 
resort to forceps, curettes, spoons, hooks, and the like, for 
its removal. The different varieties of polypus forceps of 
a somewhat small size may be used for this purpose. A 
probe, slightly bent at its extremity, and introduced at the 
side of the obstruction, acting as a vectis, often succeeds 



84 DISEASES OF THE EAR. 

better than forceps. If it be grooved on its concave side 
it is more likely to engage with the obstruction. The cu- 
rette of Prof. Gross of Philadelphia, which also has a tooth 
at the opposite extremity, placed at right angles to 
the shaft of the instrument, is well adapted to the 
purpose. (Fig. 24.) Sometimes Politzer's fleam- 
shaped knife for incising the meatus (Fig. 25), may 
be passed in flatwise at the margin of the foreign 
body, and when beyond it turned so as to impinge 
against it, and if it be of a material which can be in- 
cised, a cut may be made in it so as to facilitate its 
breaking up. It may then be removed by syringing, 
or it may be drawn out bodily by the knife. In 
all these efforts the size and direction of the canal 
must be recognized, namely, that the inner end of 
the canal is larger than the middle, that the anterior 
wall has a convex curvature looking backward, and 
that when the foreign body becomes impacted it is 
more likely to be found in the antero-inferior portion 
of the inner extremity of the canal, and on account 
of the greater diameter of this portion, a pocket is 
formed from which it is difficult to dislodge the ob- 
struction. If a curette or hook is used it is better 
to pass it in the direction of the antero-inferior por- 
tion of the canal, as here the membrana is farthest 
from the external orifice, and the tendency of the 
foreign body to strike the convex curve of the an- 
terior portion of the wall of the canal will be dimin- 
ished. Where the canal is so much swollen at its 
outer extremity as to partly envelop the foreign 
body it would not be amiss to make a deep in- 
cision into it with Politzer's fleam-shaped meatus 
knife, or the canal may be dilated by a Gruber's bi- 
valve speculum. When the foreign body can be 
penetrated the spiral end of one of Gross' instruments 
(Fig. 24) may be sufficiently inserted into it so as 
to allow of its extraction. Dr. E. D. Spear, Jr., in 
Fig. 25. the Am. Jour. OtoL, July, 1881, recommends a novel 
Politzer's mode of procedure in removing foreign bodies 
^fe. 3 from the meatus. If the foreign body is in the 
outer portion of the cartilaginous meatus, "the 
fingers are now pressed firmly upon the skin close to 
and in front of the tragus, carried upward and around the 
meatus upon the auricle, and back again to their starting- 



REMOVAL OF FOREIGN BODIES FROM THE MEATUS. 85 

point; then lift up, and, the manoeuvre repeated several 
times, the foreign body will be seen to move outward, 
and will finally drop into the depression at the bottom 

of the concha When the foreign body is lying 

beyond the centre of the cartilaginous portion of the 
canal, and has even been pressed partly into the osseous 
portion, the same movements of the canal will bring it 
nearer the entrance of the meatus, or will perhaps change 
its position so that other means, such as syringing, will 
more easily remove it." This idea seems based on the 
mobility of the canal, and the method is evidently a good 
one. I have, however, no experience with it. In removing 
larvae from the ear, whether alive or dead, the hook-like 
appendage of the animal is so fastened into the tissues 
that syringing will not remove them, and it becomes ne- 
cessary to pick them out with forceps. If it is desirable to 
kill them previous to extraction, pour in a little of the 
liquor sodae chiorinat. (Roosa). 

In some instances, where the canal is exceptionally 
narrow or excessively swollen, or where the foreign body 
is so large and so firmly impacted as to make it impos- 
sible to remove it by other means, the auricle may be 
partially separated from the canal at the junction of the 
osseous and cartilaginous meatus. This is an old operation, 
performed in various manners by Von Troeltsch, Langen- 
beck, Schwartze, and by Paulas JEgineta in 660. It has also 
been recommended by Hyrtle (J. O. Green's references in 
the Tr. Am. Otol. Soc, 1881). The operation is not diffi- 
cult ; no better method can be employed than that de- 
scribed by Green (1. a). The patient must be placed 
under ether. Make a semicircular incision above and be- 
hind the auricle at its insertion, which must divide the per- 
iosteum. This may be further extended so as to sever the 
upper and posterior portion of the meatus at the junction 
of the osseous and cartilaginous portions, when the osse- 
ous meatus is well uncovered. Sometimes, however, the 
canal does not after this operation present so decided and 
satisfactory an opening as might be expected or desired, 
but by means of some of the instruments we have already 
enumerated there will be no difficulty in removing the for- 
eign body. In certain cases it might be necessary to open 
the mastoid antrum by the usual method and approach 
the meatus and tympanum from this direction. I have 
had considerable experience in opening into the meatus by 



86 DISEASES OF THE EAR. 

an incision behind the auricle, which has been referred to 
under the head of suppurative otitis. There is no difficulty 
in the operation whatever. Dr. Ely, of New York, in per- 
forming an operation for deformity of the auricle, was en- 
abled to demonstrate the feasibility of this operation. 
After the foreign body has been removed the auricle may 
be turned back into its proper position and fastened by 
sutures in the usual manner. 

A foreign body may excite an intense degree of inflam- 
mation in the meatus and tympanum, extending perhaps 
to the mastoid cells, and even to the brain itself, sometimes 
with fatal results. This is not likely to occur, however, 
unless great violence is inflicted in the efforts made to re- 
move it. Granulations and polypi are sometimes found 
in the meatus, as a consequence of the abrasion of the 
part from the presence of the foreign body. As is well 
known, any irritation of the meatus may produce a num- 
ber of reflex symptoms. In the case of irritation depend- 
ent on the presence of a foreign body in the meatus, we 
may have a cough, vomiting, epileptic seizures, paralysis 
of the face of the same side (Meyer, quoted by Roosa), 
atrophy of the arm, anaesthesia of the whole of one side of 
the body, convulsions, etc. 



IMPACTED CERUMEN. 

The meatus externus, in a normal state, secretes a ma- 
terial of a light-yellow color, which, presenting some of the 
characteristics of wax, has been denominated cerumen. In 
some cases there is so little of this secretion that it is 
hardly visible to the eye; yet, on touching the wall of the 
meatus, the sensation communicated to the finger will leave 
no doubt of its presence. In other cases there will be suffi- 
cient to smear the wall of the meatus, but not enough to 
cause obstruction. This substance is the combined product 
of the ceruminous and sebaceous glands. 

The cartilaginous portion of the meatus contains seba- 
ceous glands with their downy hairs, and ceruminous 
glands. In the osseous portion the downy hairs with their 
glands are few in number, and the ceruminous glands are 
found only on the posterior upper wall, extending often to 
the membrana tympani. The ceruminous glands resemble 
the sweat glands in many particulars, but the secretion of 



IMPACTED CERUMEN. 87 

the former contains coloring matter not found in that of 
the latter. The ceruminous and sebaceous glands, to- 
gether, secrete a light yellow, rather fluid substance, which 
consists essentially of small and large fat globules, masses 
of corpuscles of coloring matter, and cells in which single 
globules of fat and coloring matter are imbedded. In 
addition, hairs and scales of epidermis from the lining of 
the meatus, and foreign bodies of different kinds, are also 
found. 

When the cerumen has collected in considerable quantity 
and remains some time in the external passage, it changes 
its color, and forms from the loss of its fluid contents solid 
masses, (Strieker's " Manual of Histology," English transla- 
tion, edited by Buck). It is, however, prevented ordinarily, 
from remaining unduly long in the meatus, so as to become 
inspissated, by the action of the outer layer of the epider- 
mis lining the meatus. This has the property of constantly 
moving from within outward, thus carrying the cerumen 
with it out of the meatus. The time occupied in the re- 
moval of cerumen by this physiological process may be 
estimated at from one to three weeks. In some cases ceru- 
men is secreted so rapidly, according to Sir William Wilde, 
as to simulate a discharge of pus or sero-pus from the ear. 
Buck also mentions this fact. This, however, is rare; for 
when cerumen is present in any considerable quantity, as a 
rule, it is of much greater consistency than when it first 
leaves the glands, having been secreted so slowly as to be- 
come inspissated by evaporation of its fluid contents. 
This will not however, always explain the phenomena of 
large collections of cerumen in the ear. I have in mind at 
present a lady who has had, perhaps, twenty collections 
of cerumen in her ears, and I have seen a small mass, which 
had collected within five or six days, which was friable, dry, 
and quite hard. Again, in the cases to which I shall here- 
after refer, I found one where the cerumen had not been 
removed for eighteen or twenty years, yet was of a light 
color, and soft in consistency. I have a feeling which I 
cannot well explain, that in some diseased conditions of 
the glands the secretion is much thicker than normal when 
first secreted. 

The conditions which give rise to augmented secretion in 

the meatus are somewhat difficult to determine. It seems 

well-nigh a truism, that some form of irritation exists, which 

excites the glands to increased secretory activity. It will 

6 



88 DISEASES OF THE EAR. 

be seen hereafter that in most of the cases of considerable 
collection of cerumen a diseased condition, accompanied 
by increased hyperaemia of the tympanum or canal, or both, 
exists; probably also with accompanying throat trouble, 
which I had stated in the Trans. Amer. Otol. Soc. for 1872, 
p. 62, as the probable cause of the secretion. Buck (" Diag- 
nosis and Treatment of Ear Diseases") expresses similar 
views, but adds, "With regard, however, to the first step in 
the series of changes, I should rather favor the view which 
refers its origin to a reflex influence, than that which makes 
the irritation spread directly from the mucous membrane of 
the middle ear to the skin of the external auditory canal." 
Whether these explanations are correct or not, the fact 
seems to remain, that in most of the cases of considerable 
ceruminous collection there is disease in the throat, the 
tympanum, or meatus externus. In the article of my own, 
previously referred to, out of two hundred ears examined, 
most of them being impacted with cerumen, there were 
only seventy-seven with perfect hearing. The glands in 
the meatus seem to behave in quite a similar manner to 
those of the throat and tympanic cavity during a catarrh. 
In the earlier stages there is increased secretion of the 
mucous glands of the tympanum and throat, with more or 
less hypertrophy. Subsequently the opposite condition 
obtains: the glands shrivel, become atrophic, with greatly 
diminished or altogether interrupted function, as in pharyn- 
gitis sicca, or in what may be called the stage of dry 
catarrh of the tympanum. Usually in this stage of the 
disease the secretion of the glands of the meatus is just as 
much diminished as is that of the mucous membranes, 
and the result is, a meatus almost utterly devoid of ceru- 
men, although it may have been in an earlier stage im- 
pacted with it. This latter condition has been noticed by 
Troltsch (Diseases of the Ear, Roosa's translation, p. 77). 
In the one hundred ears actually containing cerumen, 
which were carefully examined, in the article above re- 
ferred to, eight were associated with perforated drum 
membranes. This seems rather unusual, and is not easy 
of explanation. Roosa, in his Treatise on the Ear, ex- 
plains that in some instances a hard mass of wax may 
so press on the membrana as to excite an inflammation 
sufficient to cause perforation. My impression is, that 
my own cases were those of old suppurative inflammation, 
and that the cerumen was an after symptom. Chronic 



IMPACTED CERUMEN. 89 

eczema may also increase the secretion of cerumen. There 
is a certain class of patients, rather inclined to be fleshy, 
with a moist and perhaps greasy skin, who, over the whole 
body exhibit activity in the glandular secretions, being 
quite opposed to another class, who are thin, with a dry 
rough skin, and presenting little evidence of activity of the 
cutaneous secretions. The former type of patient is much 
more likely to have an excess in the ceruminous secretions, 
and the latter a diminution of the same, without presenting 
in either case any actual disease of the ear. I have, how- 
ever, yet to see more than an occasional patient, whom I 
have watched for two or three years, with frequent collec- 
tions of cerumen, who did not eventually develop some 
form of otitis. The means for the natural removal of the 
cerumen from the ears maybe inadequate. Nothing is more 
common than to find a coal-heaver with ceruminous collec- 
tions in his ears. Undoubtedly the presence of dust in the 
meatus, which would naturally adhere to the cerumen, is 
sufficient to interfere with the normal efforts at removal, 
and the more it accumulates the greater the difficulty of 
removal. Undoubtedly, lack of cleanliness has somewhat 
to do with these collections, but Dr. Roosa has much to 
say about the efforts at cleanliness sometimes preventing 
the removal of the cerumen, especially if the corner of a 
towel, or a bit of sponge attached to a holder (aurilave), 
is used for the purpose, thereby forcing inward any parti- 
cles of cerumen about to drop from the meatus. I believe 
this to be frequently true. It is well to advise patients not 
to interfere with their ears, and if anything is amiss, to 
consult a surgeon. Another cause which prevents the 
normal removal of the cerumen, is the presence of foreign 
bodies in the ear. The most frequent of these are bits of 
cotton pushed into the meatus. The cerumen collects on 
the foreign body and so completely envelops it as to make 
it unrecognizable until it is removed. I once found a bug 
concealed within a mass of cerumen. Occasionally, when 
there is an excess of exfoliation of epidermis from the 
canal, the cerumen becomes entangled with it, and failing 
to be removed, collects in large quantities. Any narrow- 
ing of the canal, by whatever cause produced, prevents 
the proper escape of cerumen. Notably this is the case with 
elderly people, more especially women, whose tissues have 
become mucli relaxed, and the auditory canals somewhat 
collapsed, especially at the outer orifice, so that the ceru- 



90 DISEASES OF THE EAR. 

men becomes shut in, so to speak; and as there is a ten- 
dency of the mass to cause absorption of the soft parts, the 
cavity containing the cerumen grows larger, and thereby 
aggravates the existing condition. 

Appearances of an excess of cerumen in the ear. — Ordinarily 
nothing is easier than to diagnosticate the presence of un- 
usual collections of cerumen in the ear. The color is usually 
quite dark, and sometimes nearly black; in other instances 
it is gray or dark brown, and sometimes whitish in color 
(light gray). Rarely has it the clear, light-yellow color of the 
normal cerumen. Its consistency is almost always greater 
than the normal, sometimes being almost solid. A more 
usual condition, when it is removed en masse, is to be so hard 
as to crumble with some difficulty in the fingers. I have 
already alluded to the fact of its being sometimes fluid, and 
in one case, before referred to, where the cerumen had re- 
mained in the meatus for many years, it was quite soft. In 
Case 8 of my series, the cerumen was insoluble in water or 
any menstruum I could select, and utterly resisted the 
syringe. It occurred to me that a different quality of ceru- 
men was secreted from the normal, but as it had a some- 
what sandy consistency it may have been only an admixture 
of gritty material with the cerumen during its formation. 
Sometimes the mass of cerumen will be nodulated with a 
polished surface giving a light reflex, possibly simulating 
that on the membrana tympani. Occasionally a flake of 
dark-colored cerumen is seen covering the drum membrane, 
which may sometimes be mistaken for it. Occasionally a 
reflex is seen from the meatus, having a bright lustre like 
cholesterine crystals, which evidently depends on degenera- 
tion of the fatty element contained in the cerumen (Troltsch). 
Before the cerumen has filled the meatus it may be seen as 
a dark mass closely adherent to the walls of the canal, and 
an opening more or less fissure-like may enable us to see 
some portion of the membrana. Buck (loc. cit.) points out 
that in some instances the cerumen only covers a mass of 
epidermis, consequent on desquamative inflammation of 
the meatus, and in others a dried and hardened mass of pus, 
due to suppurative inflammation of the tympanum, is en- 
crusted with cerumen. Some of the cases I have reported, 
which were accompanied by suppurative disease, may have 
been of the latter character. The plug of cerumen, after 
removal, besides being mixed with hairs and epidermis, 
may actually be encased in the epidermic lining of the 



CERUMINOUS COLLECTIONS IN THE EAR. 91 

meatus, giving it a light-gray color. The appearances of 
the cerumen above detailed will be sufficient to settle the 
diagnosis. 

Consequences of ceruminous collections in the ear. — The inter- 
ference to the hearing from these collections depends on 
the following conditions: If the cerumen is not impacted 
nor resting on the drum-head no diminution to the hearing 
results. I have often seen a meatus nearly filled with ceru- 
men without the patient's noticing anything amiss. Deaf- 
ness often comes on suddenly, which may be accounted for 
in this manner: The canal may have been full of cerumen, 
except a little fissure leading to the membrana; the plug 
of cerumen, by a violent jolt or jar may have fallen inward, 
or so changed its position as to close up the fissure. In 
washing the ear in the morning's toilet the water may soak 
into the cerumen, causing it to swell and hermetically seal 
the meatus. A similar condition results from bathing. A 
thin flake of cerumen on the membrana always diminishes 
the hearing, and may diminish bone conduction as well. 

When the cerumen presses upon the membrana, tin- 
nitus aurium is very likely to occur, as well as vertigo, 
and possibly nausea and a feeling of faintness. A 
cough may be occasioned by impacted cerumen, or even 
if it smears the canal. Dr. Andrew H. Smith once brought 
a patient to me who had an obstinate cough which had 
no explanation from laryngeal or lung conditions. I 
found the auditory canals simply smeared with a mixture 
of cerumen, epidermis, and dust. On cleaning the ear 
carefully, the cough at once disappeared. The sympathetic 
relations between the ears, eyes, naso-pharynx, teeth, larynx, 
lungs, and stomach are well enough known. Some years 
since a patient at the N. Y. Eye and Ear Infirmary had an 
auditory canal so sensitive, that on touching a certain spot 
he would immediately vomit. He seemed amused at the 
interest he excited among the surgeons, and would smil- 
ingly allow the ear to be tickled whenever it pleased any 
one to test his peculiarity. One of the most remarkable 
consequences of ceruminous collections is related by J. 
Rudd Lesson, M.D., in the London Lancet for 1879, vol. xii. 
p. 833. A young woman had a bronchitis which had re- 
sisted treatment for several years. During the last two 
years she gradually grew hard of hearing, first in one, then 
in the other ear, until the deafness became complete. This 
resulted in an inspection of the ears, when the canals were 



92 DISEASES OF THE EAR. 

found filled with cerumen. This was removed, and the 
cough suddenly ceased and the hearing became normal. 
In the TV. Am. Med. Assoc, for 1880, Dr. S. D. Risley, of 
Philadelphia, contributes a couple of cases bearing upon 
this point. The first patient, with impacted cerumen, had 
some symptoms of locomotor ataxy. He described himself 
as feeling as though he were walking on a deeply-padded 
carpet, and otherwise being uncertain in his gait. The 
cerumen was removed, and in ten days all the symptoms 
disappeared. The other case was also one of ceruminous 
collection; the patient complained of tinnitus, loss of mem- 
ory, and giddiness. So troublesome was the latter symp- 
tom that he could not continue his work. He was dull in 
his intellect, low-spirited, and dreaded suicide. He found 
by placing his finger or a piece of cotton in the ear that 
these symptoms would temporarily disappear. On exam- 
ination a large dark mass of cerumen was found in the 
inner extremity of the canal. The latter had become en- 
larged, and the mass of cerumen was found to be loose, and 
would move about in every direction whenever the patient's 
head moved, striking the membrana with considerable 
violence. On removing the mass all the symptoms dis- 
appeared. I infer that the cause of the temporary relief 
resulting from thrusting the finger or a piece of cotton into 
the ear was the fact of its preventing the loose piece of 
cerumen from moving about and striking the drum mem- 
brane, which evidently caused all the symptoms. Drs. 
Roosa and Ely, in the Archives of Otology, N. Y., 1880, 
No. 1, p. 19, report a case of impacted cerumen in a student, 
who had the following symptoms: Great mental depression, 
and inability to concentrate his mind on a subject for more 
than a few minutes at a time. He was fearful of having to 
give up his studies. The right ear was affected; the hear- 
ing distance before removal of the mass was, for the watch, 
^-; after the removal, JJ*. In a few days all the symptoms 
disappeared, much to his delight. Epileptiform seizures 
have been traced to impacted cerumen. 

From the record of my published cases, it would seem 
that suppurative inflammation of the tympanum and im- 
pacted cerumen had some connection with each other, for, 
out of one hundred cases of impaction eight cases of per- 
forate membrane were found. What has been said in a 
previous portion of this article may explain the presence of 
cerumen in suppurative cases, but I think that a few of 



CERUMINOUS COLLECTIONS IN THE EAR. 93 

them were the result of the extication of an inflammation 
due to the presence of the cerumen, the latter acting as an 
irritating foreign body. The meatus is often damaged by 
the presence of the cerumen. Case 8 had not slept for 
three nights previous to applying for aid, on account of 
pain, the result of otitis externa. After the removal several 
large granulations were found in the canal. Case 33 ex- 
hibited redness of the meatus, as though the cerumen had 
caused considerable irritation. Case 51 had a reddened 
and excoriated meatus. In Case 70 there was redness and 
swelling of the auricle five days previous to the removal of 
the cerumen, but without pain. Case 16 had pain in the ear 
five days previous to the removal of the cerumen. In Case 
26 the patient had caught cold and suffered from pain in the 
ear. Case 29 had had pain in the ear five days previous 
to the removal of the cerumen. It is easy to understand 
that a meatus filled with hardened cerumen would take on 
inflammation on slight provocation, and that a moderate 
degree of swelling would render the part more painful on 
account of the pressure which would rapidly ensue. 

The prospect of recovery from the deafness accompanying the 
impaction depends upon the following considerations, to 
wit: If there is no disease of the ear, perfect recovery of the 
hearing results, as far as I have observed, or witnessed from 
the experience of others. One of the cases I reported in the 
above-mentioned series had an impaction of cerumen exist- 
ing twenty years, but the patient recovered with good 
hearing. It must, however, be remembered that this was 
exceptionally soft, and less liable to do harm by pressure 
upon the delicate mechanism of the middle ear than hard- 
ened masses. Ordinarily there is only a little pressure on 
the drum membrane, which pushes it inward, but which 
may again be restored by Politzer's inflation; a few days at 
most suffices to correct the malposition. It has already 
been seen, that in the majority of the cases before referred 
to, other affections of the ear accompanied the cerumi- 
nous impaction, and the removal of the cerumen could 
scarcely improve the hearing because the deafness mostly 
depended on the disease accompanying the ceruminous 
collection. If the patient fails to hear a voice some- 
what elevated, a foot or two from the ear before the re- 
moval of the cerumen, it is evidence that the deafness 
does not all depend on the cerumen, for an ear may be 
stopped as tightly as a finger may do it, and yet hear a voice 



94 



DISEASES OF THE EAR. 



two or three feet, and the cerumen hardly does more than 
this. There is one exception to this: if the membrana is 
pressed upon, a greater degree of deafness may result than 
would otherwise, and bone conduction may even be weak, 
contrary to the rule. A suspicion of labyrinth affection 
might also be raised. As far as I know, removal of the ceru- 
men will relieve all the symptoms caused by its presence. It 
is stated by some that the cerumen, in its constant growth 
by accretion, may enlarge the meatus, by causing absorp- 
tion of its soft parts, and in some instances even of the 
bone itself. I am extremely doubtful that bone has been 
absorbed by this pressure ; leastwise, I have never seen a case 
where this could be verified. The membrana is often red- 
dened after the removal of the cerumen. This is the re- 
sult of two factors; simply syringing the ear with warm 
water is sufficient to congest the membrana. The violent 
removal of the mass of cerumen will cause it — and if the 




G.TIEMANN & CO . 
Fig. 26.— Hard rubber basin for use in syringing the ear. 



plug rests on the drum head it cannot be removed without 
violence to the latter. The redness and erosion of the 
canal noticed in some of the cases I have reported may 
depend on the violence necessarily used in removing the 
impacted mass. 

The treatment consists in the removal of the mass, in the 
gentlest manner possible. 

The best method of doing this is by syringing with warm 
water. The latter should be a little too warm for the hand, 
for that temperature which is warm to the hand is cool to 
the ear. It is desirable to use two basins or bowls — one as 
a receptacle for clean water, and the Other to receive what 
returns from the ear in the syringing (Fig. 26). Our suc- 
cess will depend on very careful attention to every detail of 



EAR SYRINGES. 



95 



the process. The syringe to which I have affixed a flange 
and long narrow tip, I believe to be as good for the purpose 
as any other (Fig. 27). A Davidson rubber syringe may, 




Fig. 27. — Pomeroy's Flange Ear Syringe. 

however, be used (Fig. 28), but it should be provided with 
a narrower tip than that usually found upon it. A bit of 
glass tubing drawn to a point in a spirit lamp will answer 
this purpose very well — any surgeon can 
make this for himself. To prevent the 
return current from impinging on the 
surgeon's person, a circular disk of 
leather, with a central perforation for al- 
lowing it to pass over the nozzle of the 
syringe, will answer very well. (I be- 
lieve this is Dr. J. S. Prout's suggestion.) 
The objection to this syringe is, that the 
operator cannot as well hold the auricle while syringing — a 
manoeuvre of great importance. To accomplish our purpose 
in the best manner, the auricle should be grasped firmly and 
drawn upward, backward, and outward, so as to straighten 
the meatus, and overcome a somewhat relaxed condition of 
the canal, whereby it tends to collapse, and to actually 
open a canal which may have wholly collapsed. The 




J. RZ7~27DZZZS-CO 

Fig. 28. — Davidson's 
Syringe. 



Fig. 




Dr. Wilson's Bag Syringe. Is also used to perform Politzer's inflation. 



stream of water may be thrown in very forcibly at first. As 
long as it is known that cerumen remains in the ear, con- 
siderable force may with perfect safety be used. The stream 
of water should be thrown at the sides of the cerumen, and 



g6 diseases of the ear. 

on the canal — successively on every side. I have long prac- 
tised this plan, but I have found the same description in a 
book by Sir William Wilde, a man who knew so many things 
about ear surgery, so long ago. My experience is, for the 
cerumen to come out en masse after a few minutes' syring- 
ing, and often with so much force as to strike the tip of the 
syringe, so as to make itself felt. In other instances the 
mass becomes dislodged, and comes out to the base of the 
concha, where it may be caught by forceps, curette, or 
spoon. In still other instances it comes out piecemeal, 
staining the water, and producing few cerumen masses. I 
state my experience here very concisely, for I know how 
far it diverges from that of many surgeons I cannot but 
respect. For several years — at least four or five — I have 
used no means but these described, and have not in a single 
instance occupied more than one sitting of five minutes 
or less in removing cerumen from the ear. I remember 
some years since, that two or three sittings were occu- 
pied by me in accomplishing the same purpose. At the 
Manhattan Eye and Ear Hospital I occasionally have 
an assistant come to me with the statement that a given 
patient had better be sent away with some softening 
menstruum poured into the ear, and another sitting ap- 
pointed. I have answered this suggestion by going myself 
and syringing out the offending mass. In my ioo cases 
of cerumen, one case only resisted the syringe, and re- 
course was had to forceps, spoons, etc., to break up the 
cerumen, which was subsequently removed by the syringe. 
Politzer of Vienna speaks of the syringe as being adequate 
to the removal of cerumen from the meatus, in his Lehr- 
buch lately issued. Wilde, in his book on the ear, American 
edition, Philadelphia, 1853, says: "I have, however, seldom 
met a case in which, with a little care and patience, I could 
not remove the wax at one sitting." I feel sure that the 
power of the syringe for removing cerumen and a great 
variety of other foreign bodies from the ear is not suffi- 
ciently appreciated by many of the profession. About its 
harmlessness: as long as a considerable amount of ceru- 
men remains in the ear to protect the membrane, I have 
not the slightest fear of doing harm by the syringe. It is 
already seen that I do not use agents to soften the cerumen 
ordinarily — I believe it to be utterly unnecessary, except in 
very rare cases indeed. Saturated solutions of bicarbonate 
of soda are ordinarily used for this purpose, poured into 



MODE OF REMOVING CERUMEN FROM MEATUS. 97 

the ear, the latter being plugged with cotton to keep the 
fluid in contact with the cerumen. Dr. Roosa in one in- 
stance used strong nitric acid to dissolve the cerumen. Dr. 
Blake, of Boston, sometimes applies a saturated solution 
of caustic potash or liquor potassae to a limited central 
portion of the cerumen, so as to saponify the fatty portion 
of the mass. Olive-oil and glycerine have been used. 
Some are in the habit of syringing out the ear with a solu- 
tion of soda, a drachm or two to the pint of water. This 
may exert some influence on the cerumen, but much more 
in dissolving the oil in the packing of the valve of the 
syringe and rendering it unfit for use. In the very excep- 
tional cases, picks, ear-spoons, or curettes may be used to 
break up the ceruminous mass, which may afterwards be 
removed by syringing. A sharp-pointed vVire sometimes 
does well in breaking up the surface of the mass, which is 
often much harder than the interior. As I have done so 
little of this kind of work, I feel that my experience is of 
but little value. I confess I cannot possibly understand 
how many aural surgeons of undoubted ability can habitu- 
ally use instruments for removing cerumen, which act by 
spooning, or mining it out. I feel that I cannot seriously 
argue the question. In syringing it makes a great differ- 
ence whether the small and rather pointed nozzle of the 
syringe is pushed far enough in to nearly or quite reach 
the cerumen, or if there is a fissure in the mass, the nozzle 
should be inserted into it. Naturally the surgeon will 
avoid throwing the stream directly upon the mass, which 
would have the effect to drive it further in. After the re- 
moval of the cerumen, the patient should wear cotton wool 
in the ears for a few days to protect from atmospheric 
changes. The ear is also sensitive to loud sounds, and the 
cotton is an agreeable protection from these. Whatever dis- 
eased condition is found, not dependent on the presence of 
the cerumen, may be treated as detailed under the proper 
heading in other portions of this book. 

Inasmuch as the cerumen in many cases persists in filling 
the ear again and again, something should be done to pre- 
vent this. Naturally we study out the condition on which 
the secretion depends, and appeal to that. I am forced to 
confess that I occasionally meet with a patient whose ears 
fill up frequently in spite of treatment. Painting tr. of 
iodine on the canal is as good as anything. Arg. nit. solu- 
tions are serviceable. I have a patient under my care now, 



98 DISEASES OF THE EAR. 

a lady in middle life, who has nearly perfect hearing — as 
perfect as others of her age. The cerumen will collect in 
one or two weeks, sometimes sufficiently to be annoying 
to her. Nothing that I have done has succeeded in 
checking it more than very slightly. I am expecting her 
to grow hard of hearing from catarrhal otitis, but so far 
the hearing is perfect. 

DESQUAMATIVE INFLAMMATION OF THE MEATUS AUDITORIUS 
EXTERNUS AND MEMBRANA TYMPANI. 

This seems hardly worthy to dignify by a separate name, 
but inasmuch as it is frequently met with in literature, it 
can hardly be overlooked. It consists of accumulations of 
the epidermis of the canal or membrana, sometimes mixed 
with masses of dried pus, cerumen, or fatty particles; the 
latter being the result of degenerations in the collected 
mass (cholesteatomata, or pearly tumor; Lucae, Buck, Kipp, 
and others). Some form of inflammation or at least irri- 
tation must have preceded this formation. According to 
Buck {Med. Record, Dec. 15, 1877), a condition of the canal 
similar to eczema or identical with it is the starting-point 
of the affection. According to Wette — Monatsch. f. Ohren- 
heilk., No. 2, 1882 (Am. Jour. Otol., vol. iv.), — an acute puru- 
lent inflammation of the membrana may be the starting- 
point of the collection. According to Kipp (Arch. Ophthal. 
and Otol., vol. iv.), the affection seems to follow at a some- 
what remote period, an acute purulent scarlatinous inflam- 
mation of the drum cavity. According to F. Graf, — Mo- 
natsch. f. Ohrenheilk., No. 12, 1881 (Arch. Otol., vol. xi.), — it 
may follow abscess of the meatus. The collection may com- 
pletely fill the meatus. It has the appearance of a brownish- 
gray or whitish mass, with a glistening appearance, when 
fatty particles are visible. Where the membrana only is in- 
volved " inspection shows a grayish w T hite appearance in the 
place of the membrana tympani" (Wette, 1. a). Granula- 
tions and polypi sometimes are found in the meatus. The 
affection may not be painful unless the epidermis accumu- 
lates sufficiently to cause pressure, when the symptoms 
may resemble those of impacted cerumen; as vertigo, per- 
haps nausea, pain in the head, tinnitus aurium, etc. Natu- 
rally the symptoms of acute inflammation of the meatus or 
drum membrane, when present, will be added to those al- 
ready mentioned. 



TREATMENT OF DESQUAMATIVE OTITIS. 99 

One important fact, specially mentioned by Buck (1. c), 
is the tendency of the affection to recur, and frequently 
without apparent explanation. One case he mentions, in 
which the mass had been reproduced from every few months 
to a year, for four years. It then had just as strong a ten- 
dency to recurrence as at first. 

The microscopic examination of these masses reveals a 1am- 
ellated structure composed of flattened epithelial cells, crys- 
tals of cholesterine, fatty acids, and minute shining bodies, 
some round, others irregular (Kipp, 1. a). Buck's descrip- 
tion is quite similar, but he mentions the fact that the 
mass contains dried pus and cerumen. Wette (1. c.) sim- 
ply says, "A microscopical examination of these masses 
showed them to be undoubted epidermoid formations, poly- 
hedral cells destitute of a nucleus." 

The diagnosis \s sometimes difficult. Many cases of impacted 
cerumen show an epidermic covering to the mass, or at least 
epidermis is mixed with the surface of the cerumen at the 
point at which it is visible. It is also admitted that the epi- 
dermic collections are sometimes composed in part of ceru- 
men. One fact is valuable: it cannot be removed by syring- 
ing, as is the case with cerumen. Where the epidermis is col- 
lected on the membrana, or on the walls of the meatus, in 
the form of a thin whitish covering, it may resemble the 
macerated epidermis covering the parts in acute inflamma- 
tion, or it may even resemble the lardaceous material of 
aspergillus. In the last two instances, however, the parts 
are moist, and the material is easily separated from contact 
with the skin. I recently saw a case which was apparently 
one of impacted cerumen. The ordinary means were used 
for removing cerumen (syringing, etc.), but failed to dis- 
lodge the mass. It had a brownish-gray appearance, was 
evidently composed of flakes of epidermis mixed with ceru- 
men. It filled the canal. There was considerable pain, 
which had continued for some days. After a rather en- 
ergetic effort to dislodge the mass which only partly suc- 
ceeded, the patient disappeared, and has not again pre- 
sented himself. I have no doubt but this was a true case 
of desquamative inflammation of the meatus auditorius ex- 
ternus. 

Treatment. — The first indication is removal of the mass.^ 
Inasmuch as a part of the obstruction consists of fatty mat- 
ter, it will be proper to effect solution of this by means of 
tolerably strong solutions of the bicarbonate of soda (Buck). 



100 DISEASES OF THE EAR. 

After this the mass must be removed by mining it out as 
best we may, by picks, breaking up the mass and removing 
it by syringing. Bent wires may be passed in, and by a 
vectis-like movement dislodge the mass. Curettes are use- 
ful. Gross' instrument for the removal of cerumen will be 
serviceable (Fig. 24, p. 73). Where a thin flake of epidermis 
lines the meatus a small spatula is of service to scrape it 
off. The same instrument bent at right angles will serve 
to remove the collection on the membrana. After the re- 
moval of this material the parts beneath showing signs of 
inflammation or irritation require attention. Buck seems 
to place very little reliance on treatment of this kind, but 
Wette (1. c.) used in one case pulverized boracic acid and 
cured his patient in eleven days; but it must be remem- 
bered that this was an acute affection. Painting the canal 
and perhaps the membrane with tr. iodine every two or 
three days will be as effective as anything. Strong solu- 
tions of arg. nit. promise good results. 

ACUTE CIRCUMSCRIBED INFLAMMATION OF THE MEATUS 
AUDITORIUS EXTERNUS. — FURUNCLE. 

This is often an extremely painful affection, and presents 
many analogies to the ordinary boil or furuncle. The in- 
flamed point is in the cartilaginous portion of the meatus 
as a rule, although it occasionally may be located in the 
osseous portion. Furuncles are usually found in the 
neighborhood of the ceruminous glands, the sweat glands, 
or the hair follicles. It is generally believed that one of 
these glands becoming inflamed constitutes the trouble in 
question. Lowenberg, in the Progres Medicate, Nos. 27 to 
36, 1881, has devoted much study to the germ theory of 
Pasteur, as applied to the causation of furuncles in the ear. 
He believes that a microbe peculiar to the furuncle, and be- 
longing to the family of the micrococci, is introduced into 
the orifices of these glands and causes the inflammatory 
attack. The boil often has a " core," which Thomas Barr, 
in the Glasgow Med. Journal, describes as being " composed 
of a slough of connective tissue, or a necrosed follicle or 
gland, around which there is more or less purulent forma- 
tion." I have not often seen this " core," which most authors 
describe as being a pretty constant characteristic. As a rule, 
in the outset there is but a single furuncle, and though a 
considerable number maybe subsequently developed, there 



FURUNCLE OF THE MEATUS EXTERNUS. IOI 

will not be present more than one at a time. The subjective 
symptoms are at first only a little itching or a feeling of irri- 
tation in the auditory canal. Subsequently, however, this 
sensation develops into a pain, which may increase to an 
unbearable degree. As a rule, the throbbing character pe- 
culiar to tympanal disease is wanting, unless the boil is near 
the inner extremity of the canal, when the tympanum may 
become congested, and be accompanied by the character- 
istic pain of middle-ear disease. In some instances the side 
of the head and region of the jaws may be painful; any 
effort at deglutition causes pain. Pulling at the auricle, 
or any movement of the jaws causing pressure on the 
inflamed part, is painful. The hearing is not usually 
affected unless from the mechanical obstruction of the 
canal due to the swollen furuncle; or when the deeper 
parts of the canal are involved, deafness may result from 
the tympanal complication. Tinnitus aurium may some- 
times be present, but is not likely to exist unless there is 
considerable pressure of the inflamed tissues on deeper 
parts or pressure from confined pus in the meatus, or from 
some possible tympanal complication. Sometimes the sys- 
temic disturbances may reach the point of high fever, delirium, 
and even convulsions, the patient being very ill indeed. 

The appearance on inspection is not as characteristic as one 
could desire when attempting to make a diagnosis. Some- 
times the canal is swollen so that nothing can be seen : 
there may be a furuncle, tender to the touch of a probe, but 
the excessive swelling prevents this observation from being 
made. More frequently, however, some point of greater 
swelling calls attention to the fact that a furuncle exists; if 
this be touched with a probe, exquisite pain may be elicited, 
localized swelling, tenderness, or soreness being the char- 
acteristic condition. The color of these swellings is fre- 
quently similar to that of the surrounding meatus, but may 
sometimes be pale, and at other times somewhat reddened. 
After from one to several days (according to its depth), the 
boil will rupture by a small opening, discharging only from 
one to several drops of thick cheesy-looking pus, which 
escapes slowly and not always giving the expected relief to 
pain. The site of this rupture may be bounded by rather 
jagged edges, from which granulations sometimes spring. 
The abscess cavity may present a considerable hollow, as 
the inelastic quality of the parts seems to prevent collapse 
of the walls after the evacuation of the pus. The discharge 



102 DISEASES OF THE EAR. 

from the furuncle may so irritate the canal as to excite dif- 
fuse inflammation. When the inflammation extends deep- 
ly into the cartilaginous region of the canal, the auricle may 
be involved in a chondritis or perichondritis, and much mis- 
chief result. Abscess of the parotid gland sometimes re- 
sults from the extension of the furuncular inflammation. 
The mastoid region may sometimes be involved, although 
this is not frequent. 

The duration of the disease in favorable cases may be a 
little more than a week; in others, especially if furuncles 
recur, the patient may be tormented with the affection for 
months. Troltsch, in Roosa's translation, relates the case 
of a man, whom, for twelve years he treated for furuncles of 
the meatus. The boils regularly recurred, first in one, 
then in the other ear, at intervals of from two weeks to two 
months. At each attack there was febrile disturbance, and 
the patient was obliged to spend some days in bed. 

The causes of furuncle are not always easy to determine. 
Facts adduced by Lowenberg and others seem to afford sub- 
stantial support to the view that bacteria act as its exciting 
cause; this, however, can scarcely be considered as definitive- 
ly established. Age and sex have an influence, adults being 
much more subject to the affection than the extremely youth- 
ful or the aged. Females seem to be afflicted oftener than 
males, especially at the climacteric period. Those of 
strumous habit, or where any influence has acted depress- 
ingly, are more liable to the disease. I have seen a much 
greater number of cases in warm weather than in cold. 
Again, I have seen so many cases at a given period that I 
could not resist the impression that an epidemic influence 
was at work. This opinion has been held by others. Any 
form of traumatism may bring on a furunculosis, as pick^ 
ing or scratching the ear when an itchy feeling is experi- 
enced; or an awkward attempt made to clean the ear with 
a bit of stick or a swab. Ear-washes of various kinds have 
been known to excite the affection. I am certain that a 
strong solution of arg. nit. will do it, and Troltsch (loc. cit.) 
states that a solution of alum will also. Eczema of the 
meatus will sometimes result in furuncular disease. An 
irritating discharge from a suppurating ear may act as its 
exciting cause. Collections of cerumen and epidermis may 
cause furuncular inflammation. The general application 
of cold to the ear, whether of air or water, has been known to 
cause furuncle. [Erysipelas of the scalp may cause furuncle.] 



CIRCUMSCRIBED INFLAMMATION OF THE MEATUS. IO3 

The diagnosis is not usually difficult. The absence of 
deafness when the canal is open and there is no discharge, 
with no carious teeth to explain the pain, and a localized 
swelling, which is tender to the touch, are conditions 
which make the nature of the affection certain. If there is 
discharge from the suspected part it must be wiped away, 
so as to enable the hearing to be estimated accurately. If 
the swelling of the walls of the canal closes it, there is no 
method of certainly diagnosticating the nature of the affec- 
tion, unless a probe touches some tender point. When the 
swelling is near the membrana there will be much trouble 
in making a diagnosis. Sometimes there may be a local- 
ized swelling in the canal which communicates with the 
mastoid. If on opening it a deep fistula is found, the evi- 
dence will point to its being a mastoid complication. The 
finding of a minute spot in the canal which gives signs of 
fluctuation when touched by two probes is well-nigh diag- 
nostic of the presence of furuncle. Sometimes a reddened 
and tender exostosis may simulate a furuncle, but it is of 
stony hardness, although it may be tender to the touch. 
Moreover, the fellow ear may have a similar swelling, which 
is not often the case in furuncle. 

The prognosis is favorable. If the hearing, by reason of 
the furuncles developing at a point near the membrana, is 
somewhat lowered, it subsequently returns. The recur- 
rence of the affection is what is most to be dreaded, and it 
cannot always be prevented. Witness the case previously 
reported from Troltsch. Sometimes a diffuse inflammation 
of the meatus follows the affection, which is often of con- 
siderable duration, and may affect the hearing. If the 
granulations which sometimes spring from the edges of the 
rupture of the furuncle are allowed to grow without hin- 
drance, the canal and the membrane become macerated 
from the discharge, and an inflammation of these parts may 
be the consequence. Occasionally the cavity of the abscess 
fails to close promptly, owing to the non-elasticity of its 
walls. When the furuncle has extended deeply into the 
cartilage of the meatus there is some danger of destruction 
of a portion of it, and even of extension to the cartilage 
of the auricle. 

Treatment. — Before the inflammation has advanced suffi- 
ciently to result in the formation of pus, the treatment 
should be directed towards relieving pain. Very few fu- 
runcles result in resolution. The weight of authority seems 
7 



104 DISEASES OF THE EAR. 

to be in favor of making early incisions, whether pus be 
evacuated or not, the relief of tension and the depletion 
resulting from the incision being the principal explanation 
of the relief to the pain which frequently ensues. I do not 
often make incisions of furuncles before some signs of 
fluctuation appear, unless there is considerable localized 
swelling. The operation is very painful, the pain continu- 
ing after the incision has been made, especially if no pus 
has been evacuated. Painting the furuncle (or the tender 
part of the meatus) with tr. of iodine often relieves pain, 
and in some instances aborts the inflammation. Arg. nit. 
in saturated solutions has more power in aborting furuncles, 
but it leaves a black crust which acts as a foreign body and 
may subsequently give trouble. Warmth, moist or dry, is 
almost always soothing to the part. If the ear be soaked 
too long with moist warmth, the canal is prepared for a 
chronic diffuse inflammation, and the tendency to granula- 
lations, which always exists in this affection, is greatly in- 
creased, and in some instances the moist applications aggra- 
vate pain. Dry warmth is ordinarily preferable. The 
most elegant mode of employing it is to place a rubber bag 
filled with warm water upon the auricle ; the temperature 
of the water must not be too high ; be guided in respect 
to this by the sensations of the patient — make it agreeable. 
Common salt heated and placed in a bag is a good applica- 
tion. A readier method is the use of hot water in a bottle ; 
lay the ear on the bottle, the latter being wrapped in a nap- 
kin. The leech, which is so valuable in middle-ear disease, 
often fails here — it is not always easy to explain why. 
From one to four may be applied as near the painful point 
as possible — this will be within the canal, or near to it. If 
relief is to follow their use, it is likely to occur in an hour 
or two ; if not, do not repeat them. Magendie's solution of 
morphine dropped into the ear may sometimes do good, 
or a solution of atropine, four grs. to the ounce of water, 
may be used. In the latter instance watch the pupil for 
evidences of the systemic effect of the drug. The last- 
named remedies are not very reliable. Often we are com- 
pelled to use morphine internally to relieve the pain. After 
pus has formed there is little question of the propriety of 
evacuating it. By introducing a couple of probes and 
pressing on the suspected swelling, the presence of pus 
may be indicated by fluctuation, or a single probe touch- 
ing a point where pus is present, the tissues will sometimes be 



CIRCUMSCRIBED INFLAMMATION OF THE MEATUS. 105 

found softer or more yielding than neighboring parts. The 
apex of this swelling will sometimes be found of a lighter 
color than adjacent parts, and possibly the skin may be 
macerated. My practice is to open these boils with a punc- 
ture rather than an incision. Nothing can be more painful 
than a long deep incision of a furuncle, and I feel that the 
indication for the incision is the evacuation of pus rather 
than the relief of pressure by extensive divisions of tis- 
sues, which is so successful in whitlows. The instrument 
I use is a Graefe cataract knife, which makes only a nar- 
row puncture. The pus being thick, it frequently requires 
pressure with a probe to cause its evacuation. It is also a 
good manoeuvre to pass in a small probe and break up 
the thick contents of the pus cavity, when its extrusion 
becomes much easier. This operation may need to 
be repeated at first every day or sometimes oftener, es- 
pecially if the abscess again fills and causes a return of the 
pain. Another objection to a long incision is that it heals 
very slowly, although it does allow of the free evacuation 
of pus. After the incision the ear needs to be syringed fre- 
quently to keep it clean. Often it will be necessary to 
wipe out the canal carefully with cotton on a probe. In- 
deed, when the canal is full of pus, possibly exerting some 
pressure, a thorough cleansing with the cotton will relieve 
pain and add to the comfort of the patient. To do this 
properly it will often be necessary to draw the auricle up- 
ward, backward, and outward, when the canal, which pre- 
viously may have been in a state of collapse, will gape suffi- 
ciently to enable us to cleanse it thoroughly. After a few 
days, if the abscess cavity fails to close, it will facilitate 
matters to rub well into it a strong solution of nitrate 
of silver by means of cotton on a holder. As to the 
propriety of opening the abscesses at all, the following ob- 
servations made by Dr. Buck, in the Am. Joicr. of Otol., 
vol. ii., 1880, p. 28, are in point. In 17 out of 28 cases the 
furuncles were incised. In 8 cases, or nearly one half, de- 
cided relief was afforded. In one third of the remainder 
no relief was experienced, or it was at least temporary. 
In the n cases where no incision was made the stage of 
pain was the same as in those which were incised, namely, 
five to seven days. Buck explains that owing to the tubu- 
lar shape of the canal there is a mechanical difficulty pre- 
venting the proper gaping of the incision. The granula- 
tions which, with some frequency, spring from the sides or 



106 DISEASES OF THE EAR. 

bottom of the abscess cavity, consequent on languid re- 
pair, may be treated exactly as those found in the tympa- 
num. These polyps are identical in structure with those 
found in the tympanum, except in their epithelial covering, 
which is of the laminated, flat, or trabecular variety, resem- 
bling somewhat the epidermis. I remove these by forceps 
if necessary, and cauterize their bases. A saturated solu- 
tion of arg. nit., or the crystals of the same fused on a 
probe, do excellent service. It may be necessary to bend 
the probe at right angles, the better to properly reach the 
part. Fuming nitric acid may be used with the cotton on 
a holder. Care needs to be taken to wipe off any excess of 
acid, for it should never be allowed to flow upon neigh- 
boring parts where healthy tissue would be destroyed. 
After the patient has fairly recovered from the furuncle, 
the canal may still remain more or less diseased, being in a 
condition of diffuse inflammation. These symptoms are 
met by ear-washes similar to those used in suppurative 
otitis. 

Tr. of iodine painted on the canal is very often useful, 
although it sometimes is rather painful. Arg. nit. is also 
of value applied in the same manner. The ears may be 
filled with a bit of cotton wool to protect them from changes 
in the weather for one or two weeks after recovery. Inas- 
much as it is usually admitted that the constitutional con- 
dition is at the bottom of the frequent relapses, much may 
be done by appropriate treatment directed to this condition. 
A great variety of tonics are indicated, at the head of 
which stand quinine and iron. Any faulty condition in 
the system must be looked after. Often great exhaustion 
from overwork must be recovered from. The stomach and 
bowels require attention. Change of air and scene are 
often indicated. Sulphide of calcium maybe tried with the 
hope of arresting the purulent formation, given in doses of 
from -^h to i tn °f a grain every three or four hours. I can- 
not say that I have seen any great results from its use, but 
many physicians of the highest scientific attainments be- 
lieve firmly in its efficacy. Small alterative doses of sul- 
phur often act well. 

Von Troltsch has great confidence in Fowler's sol. of 
arsenic. It certainly does well in other forms of suppura- 
tion, as impetigo for instance. Iodide of potass, seems 
sometimes to act well. Inasmuch as the antiseptic treat- 
ment is much approved of by many, it has been thought 



TREATMENT OF FURUNCLE OF THE MEATUS. I07 

advisable to insert Politzer's antiseptic treatment of fu- 
runcle. It is from his Lehrbuch der Ohrenheilkwide, vol. ii. 
p. 682. 

" The introduction of the antiseptic treatment marks a 
real advance in the therapeutics of furuncular disease. 
While under the former methods of treatment cases of 
multiple furuncle were much more frequent, and they were 
not able to prevent fresh eruptions; but under the antiseptic 
treatment, however, recurrences of fresh eruptions are much 
more rarely observed. 

" The most effective applications are carbolic acid in the 
form of carbolized glycerine, 1 part to 30, to be applied with 
a brush, and boracic acid in powder (Morpurgo), or alcoholic 
solution, 1 part to 20 (Lowenberg), to be instilled into the 
meatus. These applications may be made either before or 
after the opening of the abscess. I have seen resolution of 
a furuncle occur, after brushing it over repeatedly by these 
agents, without its opening into the meatus. 

" Lowenberg obtained the same result in a case where 
incision could not be practised, by the instillation of an 
alcoholic solution of boracic acid. This method is, at all 
events, to be preferred to the cauterization with nitrate of 
silver, proposed by Wilde, or the very painful injection into 
the furuncle of a five-per-cent solution of carbolic acid, re- 
commended by Weber-Liel. 

"After division of the furuncle, the incision should be 
immediately brushed over with the carbolized glycerine or 
boracic-acid solution, to act on the parasites and prevent 
the emigration of bacteria to the neighboring follicles. 
The instillation of the boracic-acid solution should be con- 
tinued until the opening in the furuncle is closed by cica- 
trization.". 

DIFFUSE INFLAMMATION OF THE MEATUS AUDITORIUS EX- 
TERNUS. 

This affection consists of an inflammation of the cuticu- 
lar lining of the meatus and subcutaneous connective tis- 
sue, and of the outer or dermoid layer of the membrana 
tympani. The inflammation in many instances, however, 
extends much deeper, involving the periosteum and peri- 
chondrium of the meatus, and often attacks all the layers 
of the drum membrane. 

It varies in degree from the most violent suppurative in- 



108 DISEASES OF THE EAR. 

flammation of these parts with destruction of tissue, to the 
mildest form of inflammation of the skin, with scarcely 
other symptoms than a slight itching in the ear and partial 
desquamation of the epidermis of the canal. 

The affection is very frequently secondary to inflamma- 
tions of neighboring parts — as of the tympanum, auricle, 
various cutaneous affections of the scalp and face, etc. 

The subjective symptoms, as might be expected, are ex- 
tremely variable. If the disease is of the acute variety, 
with great swelling, especially if it is consequent on tym- 
panal disease, excessive pain, sense of fulness and throb- 
bing, will be present. Notably there will be pain during 
any movement of the jaws, or when the auricle is handled 
somewhat harshly. The same symptoms are also likely to 
accompany those varieties of the disease which depend' on 
the exanthemata. 

Deafness or tinnitus are not likely to occur unless the 
inflammation also involves the tympanum ; then these 
symptoms will be in accordance with the kind and degree 
of existing tympanal trouble. If the canal alone is in- 
volved, but is swollen so as to mechanically obstruct the 
passage of sonorous undulations to the tympanum, there 
will be deafness. 

In milder cases, or in those which are in the sub-acute or 
chronic stage, there may be only an itching, and possibly a 
hot or burning sensation in the canal. In these there is 
great danger to the patient from his inclination, which is 
often irresistible, to introduce a variety of articles into the 
ear for the purpose of relieving the unpleasant sensation. 

In a subsequent division of this subject it will be seen 
how mischievous this practice is. 

Objective Sympto?ns. — In some instances little or nothing 
will be seen, because the canal is closed. Where inspection 
is possible, we may see the following peculiarities: In acute 
or sub-acute cases a discharge of pus, blood, mucus, or se- 
rum, as in suppurative otitis media, will be observed, which 
on being removed reveals a macerated condition of the 
canal and membrana, as in suppurative otitis. Here and 
there the epidermis may be removed so as to exhibit a red- 
dened surface. Occasionally small polypi may be ob- 
served, but these are infrequent rather than otherwise. 
Sometimes the whole canal may be denuded of epidermis, 
and the surface exposed may be reddened and somewhat 
rough, with here and there minute elevations, as though 



DIFFUSE INFLAMMATION OF THE MEATUS EXTERNUS.IO9 

granulations were about to spring up. In a later stage, 
when the discharge has ceased, or in those cases in which 
a discharge has never existed, the canal will present a 
scurfy appearance, with more or less redness of the surface, 
when the epidermis has been removed. In those cases, as- 
sociated with eczema of the auricle, the canal may present 
an excessively scurfy appearance, with here and there fis- 
sures, which, on being roughly handled, will bleed. The ap- 
pearances described in the canal are often repeated on the 
drum-head. 

In the diffuse otitis accompanying suppurative inflamma- 
tion of the tympanum, deep ulcerated grooves may fre- 
quently be seen in the lower part of the meatus, conse- 
quent on the corroding action of the discharge. 

In old cases of catarrhal or proliferative otitis media the 
canal will look reasonably normal, except there is little or 
no cerumen present; and the inner extremity of the meatus 
may be smooth, shining, and red, with few or no signs of 
loosened epidermis. These reddened portions are some- 
times tender to the touch, and sensitive to cold. Another 
phase of the disease exhibits a canal smeared with an ex- 
cess of cerumen, which on removal reveals a surface more 
or less reddened, and somewhat tender. In a very few in- 
stances the inflammation extends outward so far as to 
cause some redness and cedematous swelling in the mastoid 
region. 

The etiology may be stated as follows : Inasmuch as the 
disease is rarely primary, but depends on inflammation of 
adjacent structures, we must look to them to account for 
the presence of the inflammation. 

A large percentage of cases of diffuse inflammation of the 
meatus depends on tympanal trouble, the inflammation hav- 
ing involved the whole of the tympanum, including the der- 
moid layer of the membrana; and it requires only a glance 
to see that the inflammation having once involved the 
dermoid layer of the membrana, readily extends to the lining 
of the contiguous derma of the meatus. It is well-nigh 
impossible to have a decided inflammation of the tym- 
panum, whether acute or chronic, without the meatus 
becoming involved. It is true that in many of these cases 
only the inner extremity of the meatus may be inflamed. 
In high degrees of inflammation of the tympanum it is not 
uncommon to see the meatus closed by the inflammatory 
swelling, and in old catarrhal cases nothing is more com- 



IIO DISEASES OF THE EAR. 

mon than to see the inner end of the meatus reddened, and 
perhaps tender from a chronic diffuse inflammation, de- 
pendent wholly on the middle-ear disease. In mastoid dis- 
ease it is not uncommon to see complications of diffuse 
inflammation of the meatus; but these are, as a rule, rather 
of the circumscribed variety, and are also often associated 
with bone destruction. In furuncle, if the abscesses are 
numerous and the repair is languid, a diffuse inflammation 
of the canal often results. 

All inflammatory affections of the auricle are liable to 
involve the meatus, as erysipelas, eczema, herpes, impetigo, 
etc. All the exanthematous affections are liable to pass 
inward and involve the meatus. Eczema of the scalp, face, 
or auricle is prone to attack the meatus, as also is herpes 
of the auricle. Causes that result in inflammation of the 
drum cavity often operate to produce otitis externa dif- 
fusa; as drafts of cold air upon the ear, cold water entering 
the meatus in bathing or while using cold-water compresses 
on the head. Usually there is no danger of cold drafts 
upon the ear when in the open air, unless there is exposure 
to a very high wind — for instance in riding, so that it is not 
usually necessary to cover the ears for protection against 
the cold. There are many irritating ear-washes which are 
liable to inflame the meatus. The subject of aspergillus 
will be considered in another place (see Index). This 
often leaves the canal in a state of obstinate diffuse inflam- 
mation, more difficult to cure than the aspergillus itself. 
Traumatism in a great variety of forms is productive of 
inflammation of the meatus: familiar examples are the 
practice of picking the ear with a hair-pin or a tooth-pick, 
ear-spoons, aurilaves, or even thrusting the finger into the 
ear to allay any itching or sense of discomfort. Collections 
of cerumen and detached epidermic scales excite an otitis 
externa. Irritating discharges from the middle ear also 
very frequently excite inflammation of the meatus. Exces- 
sive syringing of the ears, especially if the water is very 
warm, will, by macerating the part, produce otitis externa. 
Poultices act in the same manner. It has long been be- 
lieved that infants often have a discharge from the ear, the 
consequence of otitis externa excited by dentition. I be- 
lieve that in some cases this is true, being clearly a case of 
reflex influence. Troltsch states (Roosa's translation) that 
specific condylomatous patches in the meatus, as well as 
those of pemphigus, result in diffuse otitis externa. Most 



DIAGNOSIS OF INFLAMMATION OF THE MEATUS. Ill 

authors agree that patients predisposed to struma are 
more subject to otitis externa than others. 

Diagnosis and Prognosis. — It is important to determine in 
a given case, whether tympanal or mastoidal complications 
may not be of greater importance than the otitis externa, 
which is so frequently secondary to other and graver affec- 
tions of the ear. If the major part of the disease is tym- 
panal, the deafness, tinnitus, obstructed Eustachian tube and 
catarrh of the pharynx will reveal that fact. With con- 
siderable mastoid disease, a simple inspection will deter- 
mine which affection is the more important. In the ex- 
anthematous variety we must not overlook the fact that 
serious disease of the tympanum almost always accom- 
panies this form of the disease. 

Under the heading of circumscribed otitis externa, the 
diagnosis has been given between that disease and the one 
under consideration. It is worthy of remark, that a promi- 
nent and characteristic symptom of this affection in the 
acute variety is tenderness in the meatus, whenever the 
jaws are moved or the auricle is pulled upon. 

The prognosis in uncomplicated cases is always favorable. 
Whatever grave prognoses may be made depend altogether 
on the complications which may exist. It is true that 
the meatus is sometimes destroyed by inflammatory pro- 
cesses, but in such cases the disease is one commencing 
elsewhere, as in the tympanum or mastoid region, and is 
not properly a disease of the meatus. Specific affections of 
the meatus are promptly recovered from under appropriate 
treatment. The cases of this disease caused by aspergillus 
are quite obstinate to treatment; those arising from eczema 
are probably the most obstinate of all the varieties. Some- 
times, though rarely, the disease may extend to the perios- 
teum of the mastoid process, but the complication is not 
serious. Again, it occasionally gives rise to furuncles of 
the meatus. One of the annoying features of the disease 
is its tendency to relapse, especially on exposure to cold, or 
to sudden atmospheric changes. 

Treatment. — When the inflammation is acute, with great 
swelling and pain, especially if there is a feeling of fulness 
in the part, and possibly throbbing, with pain on manipu- 
lating the auricle or moving the jaws, leeching is certainly 
indicated. The leeches should be placed within the meatus, 
or as near to it as possible. If the symptoms are not 
urgent, douching with warm water is a good method of 



112 



DISEASES OF THE EAR. 



treatment. Clarke's douche (Fig. 30) or a substitute may 
be used. A competent person may douche the ear very suc- 
cessfully with a Davidson syringe. With this a stream may 
be thrown into the ear with the greatest possible gentleness. 
Warm water may be poured into the meatus and allowed 
to remain there for a time. If the inflammation threatens 
to involve the bone, free incisions through the inflamed tis- 
sues will be proper. 

In making the incision select any narrow knife — a te- 
notomy knife or a Graefe's cataract knife of the wider 
variety, or the fleam-shaped knife suggested by Politzer 
(Fig. 25, p. 74) — is very serviceable. The incision should 




Fig. 30. — Clarke's Aural Douche. 

penetrate nearly to the bone, and be of such a length as is 
indicated by the extent of the swelling. Afterwards, bath- 
ing or douching with warm water will encourage the bleed- 
ing and aid in dispersing the swelling. Some surgeons 
make two or more incisions in the canal, but ordinarily one 
is sufficient. 

Magendie's solution of morphine may be dropped into 
the ear every half hour until pain subsides. It is quite safe 
to pour into the ear a larger quantity than would be ad- 
ministered internally. If the pain should resist all other 
modes of treatment, the morphine may be administered 
hypodermically or internally. If poultices are used they 
are admissible only for a short time. Longer use is likely 



TREATMENT OF INFLAMMATION OF THE MEATUS. 113 

to soften the canal and predispose to polypi. Anodynes 
may be added, if necessary, to relieve pain. Sometimes a 
4-gr. solution of sulph. atrop. will act well as an anodyne. 
Pour a few drops into the ear every half hour, watching the 
pupil in the mean time for evidences of atropine poisoning. 
(If the pupil dilates, stop the application.) If there is con- 
siderable discharge, remove it by syringing and a little 
cotton wound upon a holder. Burnett, in his Treatise on 
the Ear, recommends cleaning the ear by aspiration, using 
a Siegle's otoscope for the purpose. He has seen minute 
points of pus exude from the canal walls during its use, and 
claims that the plan is quite superior to other methods for 
cleansing the ear. It will be seen that the treatment of the 
acute stage of this affection is quite similar to that of otitis 
media acuta, and under that topic will be found further 
details of treatment bearing upon the subject. After the 
pain has subsided there may be considerable discharge. 
The astringents mentioned under the heading of acute sup- 
purative otitis may be employed. It is, however, advisable 
to give considerable personal attention to cleansing the ear 
and making the applications. If a remedy is applied to the 
(wall of the canal by means of cotton on a holder, especially 
if it is thoroughly rubbed in, it becomes much more effec- 
tive than when used by instillation. The canal wall is 
almost always covered with detached and loosened epi- 
dermis, which effectually protects the diseased surface from 
the action of the remedy unless applied as directed. I be- 
lieve the best remedy for arresting the discharge and sub- 
duing the inflammation to be nitrate of silver in strong 
solutions — from 20 to 100 grs. to the ounce of water. If it 
is carefully applied every second day the effect will be suf- 
ficient. If the dermoid layer of the membrana tympani is 
involved, the application may also be made directly to that 
part. Sometimes the canal will have a soft, red, roughened 
look, with here and there perhaps, a nodule of granulation. 
In this class of cases the arg. nit. will act very satisfactorily 
indeed. The method of using arg. nit. solutions in this 
connection, as described by Buck in his "Diagnosis and 
Treatment of the Diseases of the Ear," N. Y., 1880, is 
worthy of insertion. He uses the silver nitrate by instilla- 
tion, and of a strength of 60 grs. to the ounce, and even 
stronger; cleanse the ear, drop in the solution, and allow 
it to remain until warmth or throbbing is produced, then 
syringe it out with warm water. A single application often 



114 DISEASES OF THE EAR. 

arrests the discharge. The stronger solution will produce 
warmth or throbbing sooner than the weaker solution. 

I have not as much experience in the use of boracic acid 
in this disease as in suppurative inflammation of the tym- 
panum. But where the meatus is denuded of its lining, and 
there is a tendency to granulations, it acts satisfactorily. Pack 
the canal with it, as directed in chronic suppurative otitis. 
Chloride of zinc, sulphate of zinc, acetate of lead, etc., may 
be brushed on the canal daily, in solutions of from 2 to 5 
grs. to the ounce of water. The chloride should be used a 
little weaker than the others. Iodoform blown into the 
meatus sometimes acts well in arresting the discharge. A 
little balsam of peru mixed with it diminishes its unpleasant 
odor (Mittendorf). 

In the cases of diffuse inflammation, seen in connection 
with " dry catarrh," where the inner end of the meatus is red- 
dened and perhaps tender, with few or no loosened epidermic 
scales, I know of nothing so serviceable as painting the 
canal with tincture of iodine. At first apply it very lightly, 
for fear of causing an intense burning pain. This may be 
repeated every day or two. The same treatment is also 
very effective in the eczematous form of this disease. I do 
not propose to treat of eczema of the meatus as a separate 
disease, having said what I desire on that subject under the 
heading of " Eczema of the Auricle." When the latter dis- 
ease has extended to the meatus, it then practically as- 
sumes the character of diffuse inflammation of the meatus. 
Sometimes the ung. plumb, carb. acts well, smeared upon 
the meatus, although as a rule greasy substances are ob- 
jectionable. They are used much less than formerly. Oc- 
casionally nitrate of silver acts well in this class of cases, 
but it is unpopular on account of its forming upon the 
meatus a black crust difficult of removal. In all of the 
scurfy forms of otitis externa, Fowler's or Donovan's solu- 
tions will be found valuable. Protecting the part from 
atmospheric vicissitudes is always indicated. This is best 
done by filling the meatus with cotton. 

Where the otitis depends on a fungus, I shall detail the 
treatment under the heading of " Aspergillus." Hebra's 
diachylon ointment sometimes is very serviceable. Where 
granulations or polypi are found, treat them as detailed 
under the head of " Management of Aural Polypi." Specific 
ulcers in the canal or gummous tumors may be cauterized 
with strong nitric acid or acid nitrate of mercury, followed 



MYRINGOMYCOSIS ASPERGILLINA. 115 

by sub-nitrate of bismuth sprinkled on the part. Iodide of 
potass, will be indicated, and possibly mercury. The bichlor- 
ide and potass, iodid. will almost certainly be useful. What 
has been said about constitutional treatment and prophy- 
laxis in tympanal disease is applicable in this connection. 



MYRINGOMYCOSIS ASPERGILLINA (WREDEN). 

This is a disease of the ear resulting from the develop- 
ment of a fungus upon the wall of the meatus and mem- 
brana tympani. It resembles in most of its varieties the 
blue mould found on bread and other articles of food 
when exposed for a certain period in a damp atmosphere, 
especially if it be in a dark place. The principal varieties 
are the aspergillus nigricans, the aspergillus flavescens, 
the aspergillus glaucus, and the otomyces purpureus. 
The fungus is more frequently found in a diseased ear, or 
one recently affected, except where there is a purulent dis- 
charge, when it is not often seen. Somewhat rarely it is 
observed in an ear otherwise healthy. Comparatively few 
cases are reported in this country, but in some foreign re- 
gions, especially Russia, the affection seems to be of fre- 
quent occurrence. In and about St. Petersburg, Wreden 
has, during a few years, reported seventy-two cases. 

The fungus occupies the meatus externus, preferably its 
inner extremity, and the membrana tympani — that is, those 
portions more excluded from the light, and where no hin- 
drance to the formation of the fungus exists. The appear- 
ance of the aspergillus nigricans is usually described as 
that of a whitish lardaceous material, moist looking, a little 
like macerated epidermis, and interspersed with numerous 
black dots. It adheres quite closely to the part, and often 
requires to be forcibly removed by forceps or a curette, when 
it leaves a surface somewhat red, but not often bleeding. 
A very constant characteristic of every variety is its ten- 
dency to reappear. From two to four days is often quite 
sufficient for the fungus to again make its appearance. In 
a case of my own I found that two days after the removal 
of the fungus minute hair-like stems appeared in the me- 
atus, having brownish tops, somewhat resembling onion 
stalks. At this stage there were few or no signs of the 
whitish lardaceous material usually described. The fungus 
was examined and found to be A. nigricans. 



n6 



DISEASES OF THE EAR. 



Weber, quoted by Wreden, describes the aspergillus 
glaucus as presenting dark-green velvet-like patches (Wre- 
den, in the Arch. Otol., vol. iv., C. H. Burnett's transla- 
tion). The otomyces purpureus of Wreden has the ap- 
pearance of a very red blood-clot. When removed it 
quickly returns, showing minute red spots, which might be 
mistaken for hemorrhages. Swan M. Burnett, in the Arch. 
Otol. for 1 88 1, No. 4, p. 319, reports another case of oto- 
myces purpureus, with a lengthy description of the micro- 
scopic appearances. J. O. Greene reports a case which he 
denominates aspergillus rubens, and which is evidently the 
same as Wreden's otomyces purpureus. 

The microscopical appearances of aspergillus nigricans, accord - 




«>X*' c «> 2-*/. 

Fig. 31. 
Microscopical Appearances of Aspergillus Nigricans. 

ing to Politzer, in his " Lehrbuch der Ohrenheilkunde," p. 
694, is as follows : " A compact felt-like mass, composed of 
epidermis and meshes of mycelium fibres, out of which 
arise perpendicularly cylindrical, tubular stems (hyphae) 
b, b' (Fig. 31), with firm walls, which frequently have a 
double contour. These stems sustain the head of the fun- 
gus, which is called the sporangium (c). This consists of a 
central bladder-like expansion, the receptaculum (d), from 
which radiate long cells, sterigmata or basidia (e), having 
round spores at their free extremities. The color of differ- 
ent varieties of fungi depends in part on the color of the 
spores; those of A. nigricans being dark brown, those of 



MYRINGOMYCOSIS ASPERGILLINA. 117 

A. flavescens and A. glaucus yellowish or greenish, and 
those of A. fumigatus dark gray." 

Wreden (loc. cit.) thus describes the microscopic appear- 
ances of the otomyces purpureus : " The mycelial layer con- 
sists of delicate, very transparent, colorless, branching, and 
septate rootlets, from which the stronger fructiferous hy- 
phens arise. These fertile hyphens, with double contour, 
manifest at different places, like the fructiferous hyphens in 
the varieties of aspergillus already found in the ear, trans- 
verse septa. The width of the broadest of them is 0.00572 
mm. to 0.00715 mm. The wall of the fungus — that is, the 
double contour or outline — is of a bright yellowish-red color, 
and is 0.00143 mm - thick. The fruit end of the hyphen is 
composed of a comparatively very large, red, round, vesicular 
sporangium, which consists of a thick-walled capsule and a 
number of round spores which completely fill the cavity of 
the capsule. The diameter of the larger sporangia is 0.0572 
mm. to 0.06435 mm.; that of the smaller ones is 0.0014 mm - 
to 0.0429 mm. The thickness of the capsule wall = 0.00143 
mm. to 0.00214 mm. Upon the younger, less developed 
sporangia we are able to distinguish, between them and 
their hyphens, a separation by means of a plain or some- 
what arched septum. These unripe sporangia are of a 
brighter, yellowish-red color, have a thick wall, and are 
filled with a finely granular protoplasm, from which, as de- 
velopment advances, the round-celled spores are developed. 
The spores are small, bright-red (by transmitted light), 
round cells of a diameter varying from 0.00286 mm. to 
0.00429 mm., which before germination show only a simple 
smooth contour and bright-red homogeneous contents. 
The germinating spores, on the other hand, show a dis- 
tinctly double contour or outline, and a dark, eccentric 
nucleus, the spores having now attained a diameter of 
0.00715 mm. to 0.00858 mm. After the rupture of the ripe 
sporangium the spores pass into the open air and distribute 
themselves over the surrounding neighborhood." 

Subjective Symptoms. — These are usually stated to be itch- 
ing, smarting, burning, a sense of fulness, pain, tinnitus 
aurium, vertigo, and diminution of the hearing, and after 
a day or two a serous discharge. Out of seventy-four 
cases, Wreden (loc. cit.) found twelve in which there was no 
pain nor itching, and four in which there was no pain 
nor tinnitus aurium. In the Tr. Am. Otol. Society for 
1869, Dr. J. O. Green graphically describes some of the 



Il8 DISEASES OF THE EAR. 

symptoms of aspergillus as it appeared in his own ears. 
He says: " In August I felt some ill-defined irritation in the 
ears, attended by a slight serous discharge, just enough to 
be felt with the fingers; this, however, soon ceased without 
any treatment, and was only recalled to mind on a return 
of the trouble in the next November, when I noticed in both 
ears the same slight serous discharge, with pricking, itch- 
ing, and occasional slight pain and feeling of fulness in the 
ears. The hearing was found by the watch to be somewhat 
impaired." The pain is not liable to continue more than a 
few hours, or a day or two, when the discharge makes its 
appearance, and the membrane is not so closely adherent to 
the parts as at first. In some cases, however, especially when 
the canal is nearly or quite full of the fungus, the pain may 
continue until it is removed. If the symptoms all depend 
on the presence of the fungus, removal of the latter disposes 
of them, but very frequently the hardness of hearing and 
tinnitus will depend on some antecedent disease. 

The consequences of aspergillus in the ear are ordinarily not 
serious. It often induces an inflammation of the dermal 
lining of the meatus and membrana. Infrequently it ex- 
tends to the subcutaneous connective tissue. The diffuse 
otitis externa resulting from the fungus is sometimes long 
in disappearing. Occasionally, according to Wreden, an 
otitis externa circumscripta may be a consequence of the 
fungus. Politzer, quoted by Wreden, has observed the 
fungus to involve the tympanum itself, and result in serious 
complications. It is the expressed belief of Wreden that 
the fungus cannot remain long in the meatus without doing 
harm. 

The diagnosis is made almost altogether by the micro- 
scope. 

The causes of the formation of the fungus in the ear are 
twofold : sporules of the aspergillus may be floating in the 
air and come in contact with the meatus, or this contact 
may be accomplished by using a speculum which previously 
has been inserted into an ear affected with aspergillus; and 
secondly, the ear must be in a condition to provide a lodg- 
ment for these spores. Dried or decomposed products of 
inflammation in the canal and on the membrana, or the des- 
quamated epidermis accompanying eczema, furnish favor- 
able conditions for the development of the fungus. Oils, 
ointments, salves, etc., when used in the ear, may decom- 
pose and furnish a favorable nidus for the reception of the 



TREATMENT OF MYRINGOMYCOSIS ASPERGILLINA. II9 

fungi. If the ear is frequently cleansed there is less liabil- 
ity of the parasite to effect a lodgment. Dampness favors 
their development; this may account for the fact that many 
cases have been reported from Russia, where so large a 
number of the people live during a long winter in damp, 
often filthy and ill-ventilated houses. Steudener and De 
Barry, quoted by Wreden (1. c), state that " aural fungi will 
be developed on any dead organic substance which accu- 
mulates in the auditory meatus or upon the membrana 
tympani, and that, finally, when they are thus developed 
upon the membrana tympani they will act like foreign 
bodies and excite an inflammation in this delicate struc- 
ture." 

The influence of age and sex in the development of the 
fungus is shown in Wreden's tables. Out of his seventy- 
four cases fifty-one were males and twenty-three were fe- 
males. The youngest patient was 13 years old; the oldest 
was 69. He has never found myringomycosis in children, 
and rarely in the very aged. Fifty-two out of the seventy- 
four cases were affected in one ear only, and eighteen in 
both. Of the latter, only six had the fungus in both ears 
at first; the remaining twelve had the fungus in only one 
ear, and not until from two to four weeks did it appear in 
the other. He has never found but a single form of fungus 
in both ears of a given patient. 

Treatment. — The first thing to be accomplished in a case of 
aspergillus, is the removal of the fungus. If it has recently 
formed, it is likely to adhere so closely to the part that it 
requires forceps or a curette to remove it. It is not always 
indicated to make special efforts, however, to do so, for 
there is more likely to be pain consequent on the removal 
1 than later on; and the forcible removal of the fungus may 
aggravate any existing inflammatory symptoms. A little 
later on the ear begins to discharge a thin serous fluid, and 
the membrane has become somewhat loosened, when it 
may frequently be removed by syringing. I do not on the 
whole believe that syringing the ear with warm water and 
removing the fungus will always result in cure, although 
many high authorities assert to the contrary. Indeed, too 
much soaking of the ear may furnish a favorable soil, on 
which future fungi may flourish. The remedy first recom- 
mended by Wreden still holds its ground — the hypochlo- 
rate of lime. It may be used in the strength of two grains 
to the ounce of water, two or three times a day, by instilla- 



120 DISEASES OF THE EAR. 

tion. It is better to make the solution at the time it is 
used, on account of the risk of decomposition. It is un- 
irritating, and is very agreeable to the patient. Carbolic 
acid may be also used as a parasiticide. Twelve to fifteen 
grains to the ounce of water may be used by instillation 
several times a day. Dr. J. O. Green found it quite irri- 
tating in his own case. Dr. C. H. Burnett, in his text-book 
on the Ear, expresses great confidence in alcohol, either 
absolute or diluted, to destroy the fungi. 

My own practice has been to paint the canal and mem- 
brane, after the fungus has been removed, with a strong 
solution of arg. nit. — from 30 to 60 grains to the ounce. 
When applied to the canal, a saturated solution may some- 
times be used. I believe it to be a good parasiticide, and 
what is better, the most effective remedy for the diffuse in- 
flammation of the canal, which is such an important element 
in most cases. Apply it every two or three days. Iodoform 
freely sprinkled on the canal and membrane frequently acts 
well. Troltsch (J. O. Green's translation) recommends 
permanganate of potash, in, from a 2 to 4 grain solution 
to the ounce of water. It is better to make it fresh. One 
of the objections to this remedy is that it is somewhat 
irritating, and may add to a pre-existing inflammation of 
the canal. Tr. of iodine painted lightly on the canal after 
the fungus is removed is a good remedy, and acts well on 
any diffuse inflammation of the canal. Apply every day or 
two; if it causes pain, syringe with tepid water. 

Wreden has used Fowler's solution locally with good 
effect. 

After making an application to the canal, the ear should 
be protected from the air by carbolized or plain cotton 
wool. It may also prevent any spores of the fungus, which 
may be floating in the atmosphere, from depositing on the 
canal. Buck, in his " Diagnosis and Treatment of Ear 
Diseases," objects to syringing the ear for some time after 
an application has been made, preferring that a scab or 
scurf should form, and remain a few days to protect the 
part from further attacks of the fungus. He thinks the 
syringing often causes pain and discharge. After the 
fungus has been completely destroyed, there still may re- 
main much to be done; the canal and membrane may be 
reddened and tender, and accompanied by a discharge, or 
there may be an amount of hyperemia and pain sufficient 
to require leeches and hot applications. 



TREATMENT OF MYRINGOMYCOSIS ASPERGILLINA. 121 

The Eustachian tube may be more or less impervious, 
and naso-pharyngeal catarrh, so frequently accompanying this 
affection, may require attention. This class of cases may be 
referred to their appropriate heading, in the Index of this book, 
for further details in treatment. If the fungus seems to be de- 
veloped from the surroundings of the patient, let him be re- 
moved to a more salubrious locality, or let his room, bedding, 
and furniture be thoroughly cleaned, and the place put in such 
a state that no more spores of the fungi may be floating in the 
atmosphere of his apartment. 

A case of aspergillus flavescens recently came under my 
observation. It was that of Mrs. X., aet. 45. Four years since 
she had had an attack, which from her description seemed 
similar to her present seizure. This was treated successfully 
by an aurist from Chicago, the duration of treatment being 
between two and three weeks. 

On September, 1884, she applied to me on account of the 
condition of her ear*,. During the last month both ears had 
had a feeling of fulness in them. This symptom was accom- 
panied by itching, a burning pain, and muffled hearing. These 
symptoms had latterly grown worse. 

On inspecting the auditory canals and drum membranes, I 
found them more or less covered with a whitish lardaceous 
material resembling macerated and thickened epidermis. 

The right ear was in a worse condition than the left. The 
whole mass was removed from each ear, coming out in some 
instances in a tubular form. Syringing, wiping with cotton on 
a probe, and the use of the polypus forceps were the means 
used in the removal. Beneath this mass the skin was red- 
dened with detachment of the epidermis. The diagnosis was 
not at this time made, although some form of aspergillus was 
suspected. The patient was sent home, with directions to 
return in two days. At the expiration of that time the left 
canal contained more of the suspected material than before, 
but the right contained somewhat less. Being quite confident 
that this was aspergillus, I caused it to be examined, and the 
result was the diagnosis of aspergillus flavescens. This exam- 
ination is appended to the report of the case. 

The auditory canals, together with the drum membranes, 
were painted with tr. iodine, which caused considerable pain ; 
this was relieved by syringing with warm water. 

In two days it was found that there was very little of the 
cryptogam on the canals, but some still remained on the drum 
membranes. On the right membrane the fungus adhered so 



122 DISEASES OF THE EAR. 

closely that it required to be scraped off, thus inflicting some 
violence to the part, and causing moderate pain. The tr. of 
iodine was reapplied again, causing considerable pain. In two 
more days, on the patient's return, there was found some of the 
fungus on the canals, although the membranes were free. 
Alcohol, a 95 per cent, solution, was now used, the canal being 
filled with it, allowed to remain an hour, removed, and dry 
cotton introduced. This was repeated three or four times 
daily. It caused a little pain. In one week after the com- 
mencement of this treatment all traces of the aspergillus had 
disappeared. The canals were left somewhat reddened, but 
with little or no inflammation. The hearing was somewhat de- 
fective from a subacute aural catarrh. The Eustachian tubes 
were treated with nitrate of silver solution by means of the 
hard rubber spray instrument, together with Politzer's inflation, 
when the hearing arose to five feet in the right and four feet in 
the left, being practically normal. 

This examination was done by Dr. DwightW. Hunter, of the 
Manhattan Eye and Ear Hospital : 

Macroscopic Appearances. 

The specimen received from Dr. Pomeroy consisted of a dirty 
white membrane, closely resembling macerated epidermis, and 
tearing like wet paper. The membrane was about an inch 
long, by half an inch wide, and was rolled up around its lesser 
diameter into a tubular form of the size of the external audi- 
tory canal. The outer surface of this tube was smooth and 
uniform in color. The inner surface was more or less studded 
(very thickly in some parts) with minute dark-brown dots, 
giving the membrane the appearance of having been thickly 
sprinkled with black pepper on its inner surface. Portions of 
this deposit were gently scraped off, and, together with small 
pieces of the membrane, transferred to a slide, and examined 
under the microscope. The specimen was placed by Dr. 
Pomeroy in Miiller's fluid immediately after its removal from 
the ear, and was mounted for microscopic examination in a 
solution of glycerine and water (equal parts). 

Microscopic Appearances. 

Felt-like masses, made up chiefly of interlacing mycelium 
fibres, in the meshes of which are entangled innumerable spores, 
yellowish-brown in color, and having an apparent diameter of 
about 1" when magnified 300 diameters. The mycelium 
fibres are transparent, colorless, and more or less septate, and 



EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS. 1 23 

their diameter is about that of the spores. Where the spores 
are thickly aggregated the color of the mass is a dark brown, 
but singly the spores are much lighter in color, so that the 
specimen is one of A. flavescens rather than A. nigricans. 
From the felt-like masses arise the hyphse, colorless, transpar- 
ent, septate, double contoured tubes, slightly larger than the 
mycelium fibres, and bearing on their extremities the sporangia, 
which resemble very closely onion tops. Only a few perfect 
forms are present, but in some instances the receptaculum, with 
its sterigmata and spores, can be seen attached to the hyphen 
or fruit stalk. Scattered about are seen a few epithelial scales, a 
few fat globules, and the various parts of the disintegrated fungus. 

EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS AUDITORIUS 

EXTERNUS. 

These growths in the osseous meatus are variously des- 
cribed as circumscribed bony tumors of the meatus 
(exostoses), or as simply hypertrophies of the same, with a 
more or less regular narrowing of the meatus (hyper- 
ostoses). The exostoses are usually described as having a 
base as narrow as the rest of the growth, or often much 
narrower, being decidedly pedunculated. Of this form 
there may be from one to three or four in the meatus. Mr. 
Field, in the London Lancet for April 1, 1882, notices that 
where three or four of these nearly occlude the meatus a 
somewhat triangular fissure is left near the centre of the 
obstruction. In the case of simple hypertrophy of the 
bony walls, the narrowing of the meatus may be quite 
regular. The hyperostoses seem oftener to be found on 
the upper wall of the osseous meatus. Very frequently a 
bony growth will be found in both ears, but more de- 
veloped in one than in the other. The surface of these 
tumors is covered with a very thin skin, and often this is 
surmounted by epidermis, which may have sufficiently 
accumulated to become obstructive. Ordinarily the tumors 
are described as being quite free from sensibility, but there 
are many exceptions to this rule — redness and tenderness 
being often noticed. These growths, it is true, cannot by 
any means be accounted for in numerous instances; fre- 
quently, however, nothing is easier than to recognize them 
as consequent on a previous inflammation of the middle 
ear, either purulent or catarrhal. In some instances this 
inflammatory proliferation seems to result in the formation 
of condensed connective tissue, previous to the ultimate 



124 DISEASES OF THE EAR. 

osseous development. My own case of polypus of the 
meatus having a cartilaginous and osseous base, published 
in the Tr. Am. Otol. Soc. for 1874, p. 541, will illustrate this. 
The case is as follows: Miss. T., aet. 15 years; chron. supp. 
otitis in both ears from scarlatina ten years previous. Dis- 
charge continued with brief intermissions until the present 
time. A mucous polypus in the right ear was removed and 
did not return. The left meatus was filled to within three 
or four lines of the concha with a polypoid material, which, 
however, was of greater firmness deep in the meatus, as 
became evident on touching it with a probe. The soft 
superficial surface was removed by forceps, when a cartilag- 
inous material was found. This, together with cancellous 
bone, was removed by bone forceps to about half the depth 
of the meatus. Five days after the operation there was 
great swelling of the meatus and of the mastoid region, 
with some constitutional disturbance. After ten years the 
condition remains about as it was two months after the 
operation. The hearing was greatly improved by the 
operation. 

Another case (to be hereafter alluded to), reported by 
A. Hedinger, M.D., of Stuttgart, also illustrates this variety 
of osseous tumor. The patient was a switchman; always 
had been healthy, and formerly had good hearing; for the 
last eighteen months has had suppurative otitis, which 
latterly has been very painful. On examination, diffuse 
swelling of the parts around the ear and rise in tempera- 
ture were observed. Hearing and bone conduction almost 
gone. In the right ear there was a new formation, which the 
patient states has made its appearance since the suppuration 
commenced. This fully occluded the meatus, and was of 
bony hardness to the touch of the probe. "A dense fibrous 
tissue closely enveloped the osseous nucleus, and was con- 
nected with its surroundings by cords." Chiselling aided 
in removing a part of this tumor, as also did the laminaria, 
to be referred to hereafter. It would seem almost probable 
that some of these hyperostoses dependent on suppuration 
of the ear, may have commenced as granulations or 
polypi. In Dr. Roosa's " Treatise on the Diseases of the 
Ear" appear two cases, under the head of Exostoses, 
which further illustrate this subject. In Case III., p. 406, is 
this statement: "A gelatinous growth from the meatus was 
removed by torsion. It was found to have its origin from 
a general bony expansion of the meatus." In Case V., p. 



EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS. 125 

407, appears this statement: "A gelatinous polypus was 
found attached to the hypertrophic posterior wall of the 
auditory canal." Dr. Cocks, at a meeting of the New York 
Ophthalmological Society, presented several roundeu 
polyp-shaped bodies of bony hardness, which had been 
removed from the meatus of an ear, with a history of 
previous Suppuration. These were found on examination 
to be of the nature of true bone. Schwartze, in his " Patho- 
logical Anatomy of the Ear," (Greene's translation), says: 
" Exostoses, congenital or acquired, pedunculated or with 
a broad base, spongy or eburnated, are found" (in the 
meatus). "The eburnated may be developed from the 
spongy variety, and perhaps vice versa. Both are only 
different stages of development of the same process." He 
explains the presence of polypi or granulations in a man- 
ner somewhat different from ours, as follows: "From the 
pressure of the exostoses against the opposite wall, painful 
inflammation of the meatus with the formation of granula- 
tions may take place." Dr. James Patterson Cassells, of 
Glasgow, in the Brit. Med. Jour., December 15, 1877, seems 
to coincide with an opinion already expressed in these 
pages. He speaks of the origin of exostoses in this wise: 
A sub-periosteal abscess of the mastoid bursts into the 
meatus; granulations sprout from the opening of the ab- 
scess, and by the gradual conversion of their cells into 
bone cells, develop the true exostoses. This process 
seems analogous to the ossiflc degeneration of inflamma- 
tory proliferations occurring within the eye. 

Etiology. — Numerous causes have been assigned to ac- 
count for the presence of bony growths in the auditory 
meatus externus. Gout, rheumatism, rachitis, and syphilis 
have been stated as causes. More recently, purulent in- 
flammations of the middle ear have been ascribed as the 
cause in a majority of instances. Roosa, in his " Treatise 
on the Diseases of the Ear," has very ably presented this 
phase of the question. I make no doubt but that in many 
instances the tumors may be traced with some directness 
to a previous purulent or catarrhal inflammation of the 
tympanum. In a case (alluded to under the heading of treat- 
ment) reported by Dr. Hedinger, he states that " it is evi- 
dent that the tumor was a consecutive one, and arose in the 
course of an inflammation of the mucous membrane of the 
middle ear," although he states in the opening of the arti- 
cle that the " pathogenesis of these growths is as yet en- 



126 DISEASES OF THE EAR. 

tirely unknown, and scarcely rises above the level of hy- 
pothesis." He, however, regards the case under considera- 
tion as somewhat exceptional. I am strongly of the opinion 
that in a large number of instances no possible cause can 
be ascribed for the presence of these tumors. Dr. Knapp 
in a discussion at the International Medical Congress in 
London, in 1881, spoke of one case where syphilis proba- 
bly produced an exostosis. On the whole, the profession 
is inclined to discard syphilis as a cause of exostoses, to- 
gether with rheumatism, gout, and rachitis. Much has been 
written on the presence of exostoses in the auditory canals 
of prehistoric races and of the American Indians. These 
occur with some frequency, and various hypotheses have 
been constructed to explain the phenomenon, but, on the 
whole, rather unsuccessfully. 

Treatment. — Ordinarily, little needs to be done. If a sup- 
puration of the ear is keeping up the irritation on which 
the existence and growth of the exostosis depends, it should 
be attended to. Usually the osseous growth is devoid of 
great sensibility, but occasionally it will be tender, some- 
what painful, and the skin covering it will be red. For 
this condition it may be well to paint tincture of iodine or 
nitrate of silver solution upon it. An attempt at removal, or 
making an opening, may be made when both ears are so 
involved as to seriously impair the hearing. If there is one 
ear with good hearing, it would not be proper to operate on 
the other. Where there is pain, tinnitus, and vertigo, with 
any symptom of cerebral irritation or inflammation, an 
operation may be undertaken. If there is a discharge which 
fails to find a ready exit from the ear, with or without 
symptoms of intra-tympanal or intra-cranial pressure, an 
operation is justifiable. An opening into the mastoid 
antrum and effecting a communication with the tympanum, 
may be made, if it is not practicable to operate on the bony 
growths. It is true that an Eustachian tube of normal size 
may succeed, by frequent Politzerizations, in evacuating 
the tympanum of any collection, if it is not of too great 
consistency. But the tubes very frequently, in this class of 
cases, become obstructed, and then fail to evacuate the 
tympanum. A great variety of operations for the removal 
of the whole or a part of these growths have been devised. 

Dr. Arthur Mathewson, in " The Transactions of the 
First International Otological Congress," refers to some of 
the means which have been used to remove exostoses, as fol- 



TREATMENT OF EXOSTOSIS OF THE MEATUS. 1 27 

lows: A case reported by Troltsch had a laminaria bougie 
introduced for the purpose of dilating the meatus. It could 
not be removed until two months had expired, when small 
sequestra came away, enlarging the canal sufficiently to re- 
store the hearing. He quotes a case of Dr. Roosa's, in 
which Toynbee attempted dilatation with bougies, but they 
caused great pain and effected nothing. The patient sub- 
sequently died from retention of pus. The first reported 
case of surgical operation on exostosis of the auditory 
•meatus was by Bonnafont in £ Union Medicate, May, 1868. 
The growth filled the meatus and obstructed the hearing. 
The soft parts over the tumor were destroyed by five or 
six daily applications of nitrate of silver, and a fine rat- 
tailed file was used to bore through the bone. It was only 
after the fourth sitting, that he succeeded in gaining a start- 
ing-point for the end of the file. The boring was continued 
for ten days. After each sitting a whalebone probe was in- 
troduced to maintain the opening gained. The opening 
finally made remained for some years after, with satisfac- 
tory improvement to the hearing. Dr. L. B. Hamburg, in 
the Archiv. fiir Ohrenheilkunde, vol. x. p. 1 1 o, relates his own 
case as follows : He had deafness and tinnitus from exos- 
toses in the meatus. A drill was used by Dr. Knorre daily 
for four days, which caused much pain from the slipping of 
the instrument during the operation, and inflammatory re- 
action in the meatus. Two days from the last attempt with 
the drill a chisel and hammer were used, which caused 
severe headache. After this, forceps and drills were used 
for ten more sittings, bringing away small pieces of bone 
of cancellated structure; the operation was attended with 
great pain. Muriatic and sulphuric acids were next applied 
to the tumor two or three times a day for eight weeks, with 
small effect. The actual cautery was applied several times. 
There was then a cessation of treatment for a time, and 
after the swelling of the soft parts had subsided a probe 
could be passed between the wall of the meatus and the 
tumor. Soon after this the doctor continued the operation 
on himself by filing away the growth with a small blunt 
file, roughened on one side only. He succeeded in making 
an opening sufficient to restore the hearing and relieve the 
tinnitus. 

Prof. Heinicke operated on two exostoses in the same 
patient by means of a gouge three lines in breadth, pro- 
pelled by blows from a hammer. In one of the cases there 



128 DISEASES OF THE EAR. 

was great pain in the ear and a sense of pressure in the 
occiput on the third or fourth day after the operation. 
Both cases, however, were successful. 

Dr. Mathewson's own case was briefly this: Miss M., aged 
25 — the case was previously reported by Dr. Roosa (loc. cit.). 
The tumor arose from the posterior portion of the osseous 
canal of the right ear, and nearly occluded it. A No. 2 
Bowman's probe was passed between the wall of the mea- 
tus and the tumor into the cavity of the tympanum. The 
growth was slightly movable. Dr. Loring passed in a scis- 
sors blade, and by a boring motion somewhat enlarged the 
opening, which resulted in improved hearing. 

The patient went on without serious symptoms for nearly 
three years, when she experienced a sense of pressure in 
the head, attacks of loss of consciousness, and other cere- 
bral symptoms, which recurred at intervals for three or four 
months. Dr. Loring saw her at intervals, and proposed the 
operation which was subsequently performed. On account 
of her removal from New York to Brooklyn, Dr. Loring re- 
ferred her case to Dr. M., who thus describes her condition: 
"I found the meatus nearly occluded by the exostosis; . . . 
the growth had become immovable, and had evidently in- 
creased somewhat since the time of Dr. Roosa's report." 
No discharge; hearing much impaired. Fearing a fatal 
termination, the symptoms seeming threatening, an opera- 
tion was determined upon. Elliott's suspension dental en- 
gine was employed to propel the drills used. The patient 
was placed under the influence of ether. The integument 
over the tumor was removed by a dental instrument known 
as a scaler, by being circumscribed and scraped off with it. 
The bony growth was perforated at several points near its 
centre with the smallest of the drills — about one and a half 
mm. in diameter. The growth was eburnated and exces- 
sively hard. Drills of nearly twice the diameter of the first 
were then used to enlarge the perforations already made, 
and cause them to run together. Lateral pressure was 
made to ream out the meatus. The bleeding was so ex- 
cessive that probes were used to guide the direction of the 
drilling. The operation was continued until a drill of about 
3 mm. in diameter was used, making an opening through 
the depth of the bone somewhat larger than its diameter. 
Syringing and swabbing out with styptic cotton were prac- 
ticed during the operation. The duration of the latter was 
from twenty to thirty minutes. The hemorrhage was not 



TREATMENT OF EXOSTOSIS OF THE MEATUS. 1 29 

troublesome. The pain subsequently experienced was sub- 
dued by the warm-water douche and moderate doses of 
opiates. 

A purulent discharge soon came on. For weeks after the 
operation the meatus was so nearly filled with swollen and 
granulating soft tissue that the membrana could not be 
seen. Gradually the swelling disappeared, and an opening 
nearly the size of the meatus appeared, except that at one 
point, where there was a thin remnant of the exostosis pro- 
jecting from the anterior upper wall of the meatus, a por- 
tion of the membrana became visible. The discharge ceased 
after using astringents and nitrate of silver; no irritation 
nor unpleasant symptoms; hearing nearly normal. Dr. M. 
takes occasion to remark on the peculiar action of the 
drills — and I can verify it by my own experience — that they 
are perfectly manageable, require very little pressure to 
cause them to operate with considerable rapidity, and the 
hardest bone is quickly cut away without violence. 

This is in strong contrast to the chisel, gouge, and ham- 
mer method, and seems altogether admirable. The engine 
herewith alluded to maybe obtained of Johnston Brothers, 
812 Broadway, New York, together with a great variety of 
drills for operating. Dr. George P. Field, M.R.C.S., has 
operated according to the Mathewson method many times. 
In the Lancet for April 1, 1882, as well as in other numbers, 
he has reported cases. In one he operated five times, and 
in another six. In two cases, where the growths had a dis- 
tinct pedicle, they were broken off by a pair of stump for- 
ceps, such as dentists use for the upper jaw. Mr. Field 
gives some valuable details of his operations. At least 
three assistants are needed. The hemorrhage is a source 
of great embarrassment, and requires one assistant for that 
alone. He uses an iron guard, which he passes behind the 
tumor, so as to give a hint as to how far the work has pro- 
gressed, and to protect the tympanum. This has to be 
made to fit any given tumor. He first selects a thin piece 
of copper, and when the proper shape is determined upon, 
duplicates it in iron; he formerly used steel, but found it 
liable to break. He does not cut through the skin, but 
penetrates it by means of the drill. He uses a small drill 
at first, and enlarges this opening by one of greater size. 
The operation is regarded by him as one of great difficulty 
and some gravity, and he is in the habit of working very 
slowly and cautiously. In one instance he evident!}' 



130 DISEASES OF THE EAR. 

wounded the facial nerve in the hiatus fallopii, but the re- 
sulting paresis was soon recovered from. All of his cases 
seem to have done well. In a case of exostosis, which evi- 
dently depended on suppurative inflammation of the middle 
ear, Dr. A. Hedinger, of Stuttgart, in the Arch. OtoL, New 
York, 1881, No. 1, translation by Furst, used the laminaria 
bougie, made from the root of the plant, to dilate the canal. 
It was introduced daily. This ostosis was, however, not 
wholly composed of bone, the diagnosis of the growth being 
an " inflammatory proliferation of the papillce and of the con- 
nective tissue, with deposition of lime within it (osteoid metamor- 
phosis).^ In this case, also, the growth was accompanied by 
purulent inflammation in its neighborhood, and a consid- 
erable swelling in the mastoid region was incised, with 
evacuation of pus. Granulation tissue was also present. 
A. E. Cumberbatch, in St. Barthol. Hosp. Reports for 1880, 
relates two cases of exostosis in which the tumors scarcely 
filled the meatus, but an increase in the thickness of their 
cuticular covering resulted in complete occlusion. Both 
cases were relieved by destroying this thickened covering 
of the tumor by means of nitric acid. This rendered 
the meatus sufficiently pervious. He raises the question 
that exostoses rarely completely close the canal, except 
from the increase in thickness of the integument covering 
them. In the case of Dr. Mathewson, it will be remem- 
bered that Dr. Loring had previously introduced a blade of 
a pair of scissors, and had succeeded by this means in re- 
moving a sufficiency of soft tissue covering the exostosis to 
open the canal. Subsequent growth of the tumor, how- 
ever, again obliterated it. 



INSTRUMENTS FOR THE EXAMINATION OF THE THROAT AND 

NARES. 

A tongue-depressor or spatula is the first requisite. By 
the following wood-cuts it will be seen that a great variety 
are in use. When the posterior wall of the pharynx, uvula, 
and lateral half arches are to be inspected, a spatula re- 
sembling the handle of a dessert spoon is a very convenient 
form. A perfectly straight spatula is often well adapted to 
this work. The pocket folding spatula (Fig. 32), fulfils this 
indication very well; so also does the hard rubber hinged 
spatula (Fig. 33). While examining the throat, if the cheek 



INSTRUMENTS FOR EXAMINING THE THROAT, ETC. 131 

is drawn out laterally, a better view may be obtained of 
the pharynx. Those spatulae made with the handle at 
right angles to the depressor have many advantages, 




Fig. 32.— The Pocket Folding Spatula. 

especially in rhinoscopic work. One objection to them is 
that the patient often throws the chin downward, when the 




Hard Rubber Hinged Spatula. 



handle will fall against the breast and embarrass the ex- 
aminer. While doing posterior rhinoscopy they are a real 




Fig. 34. — Tuerck'a Tongue Spatula. 



advantage, as the patient may depress his own tongue by 
their aid. The best instrument for this purpose is Tuerck's 
(Fig. 34), which is provided with three tongue-depressors of 



132 DISEASES CF THE EAR. 

different sizes, which fit into the handle. By the upward 
bending of the stem attached to the depressor the instru- 
ment is lifted from the teeth, against which the ordinary 
spatula is so likely to impinge. Fig. 35 represents the 
right-angled folding spatula, which may easily be carried 
in the pocket. Fig. 36 represents Sass's spatula, which is a 
very elegant instrument indeed. For posterior rhinoscopy 
a small laryngeal mirror is used. The mirror here figured 
(Fig. 37), which may be denominated a rhinoscopic mirror, 
is of full size for the purpose. Fig. 38 represents two 
groups of mirrors useful for examination. In the division 
containing circular mirrors, Nos. 1, 2, and 3 may be selected 
for rhinoscopy. The oblong mirrors may be used in some 



Fig. 35.— Right- Angled Folding Spatula, 

cases where the pharyngeal orifice is narrowed by encroach- 
ing tonsils, or from other causes. For rhinoscopic exami- 
nations it is not absolutely essential to use other than 
a good gas-burner or coal-oil light; but if some form of 
condenser is needed, the one here figured, and known as 
McKenzie's, is as good as any (Fig. 39). Instead of using 
the large mirror after the manner of Tobold, as here rep- 
resented, it is much better to use it placed upon the fore- 
head, as previously described. Where gas is used, the uni- 
versal bracket of Mitchell, Vance & Co., of New York, is 
by all comparison the best. The German student's lamp 
is the best arrangement where oil is used. In Vienna, 
Schrotter uses the ordinary argand gas-burner, without a 
condensing lens of any kind. 

In using the rhinoscope, first warm it in the lamp: then 



INSTRUMENTS FOR EXAMINING THE THROAT, ETC. 1 33 



place it against the examiner's cheek to determine whether 
it be of the proper temperature (sufficiently warm to pre- 
vent moisture from collecting on it); then, with the patient's 




1 



Fig. 36.— Sass's Spatula. 




Fig. 37.— Rhinoscopic Mirror. 



tongue depressed with a spatula, perhaps held by himself, 
or drawn out'of the mouth by the patient's catching the end 
of it in the corner of a towel, pass the mirror into the pos- 
terior pharynx, if possible, not touching any portion of it 
for fear of exciting reflex contractions of the parts, when a 



134 



DISEASES OF THE EAR. 




Fig. 38.— Rhinoscopic Mirrors of different Sizes and Shapes. 




Fig. 39.— McKenzie's Condenser. 



INSTRUMENTS FOR EXAMINING THE THROAT, ETC. I35 

view of the upper pharynx, region of the Eustachian tubes, 
posterior nares, etc., will be gained. In some instances the 
mirror may gently rest on the base of the tongue, without 
provoking undue irritation. When the velum does not fall 
into proper position, direct the patient to say Ah in a pro- 
longed manner. If the velum falls spasmodically against 
the posterior wall of the pharynx, a good procedure is to 
cause the patient to breathe through the nostrils. This 
may be practised by the patient previous to the attempt at 
examination, and should be done with the mouth wide 
open. It is not often necessary to use hooks to keep the 
uvula out of the way. A rhinoscopic examination pos- 
teriorly may be made easily without hooks, etc., to manage 
the velum, or it can scarcely be done well at all where 




Fig. 40.— Roth's Bivalve Speculum. 

violent coercive measures are necessary. Sometimes, however, 
a velvet-eyed catheter may be passed into the nostril, emerg- 
ing from the mouth ; the ends being tied externally secures 
the velum, so that examinations are possible. The silvering 
on the mirror may soon be destroyed by carelessly wetting it in 
cleansing and insufficient drying, or by an excess of heating of 
the mirror in the lamp flame. It is a good rule to make the 
examination as quickly as possible, for the patient soon becomes 
fatigued and loses self-control, and consequently does not 
respond properly to directions given him. 

In Anterior Rhinoscopy the following instruments are more fre- 
quently used. The old Gruber bivalve speculum is a valuable 
means of dilating the nostrils. Theoretically the dilatation should 
be made horizontally, but in practice we frequently find that the 
opposite direction of the dilatation — that is, the vertical — will ex- 



136 DISEASES OF THE EAR. 

pose a larger surface to view. Roth's bivalve speculum (Fig. 40) 
is similar to Gruber's, and answers a good purpose. Some years 
since I picked up in a shop in Berlin a speculum I have used very- 
much since, with great satisfaction. It is Fraenkel's (Fig. 41). The 




Fig. 41.— Fraenkel's Nasal Speculum. 



screw seen at the end of the instrument operates with great rapid- 
ity, so that when inserted into the nostril it may be removed al- 
most instantly by a very moderate turn of the screw. Goodwillie's 
speculum (Fig. 42) is a very convenient and inexpensive one. If 




Fig. 42.— Goodwillie's Speculum. 

a hair-pin is bent in the shape of a double hook, as sug- 
gested by Bosworth, it is very convenient for hooking into 
the nostril, drawing the outer wall away from the septum, 
and exposing the nasal cavity. In examining this cavity it 
is very important that it be thoroughly cleansed, and it 
will often be necessary to dry the part with cotton-wool on 
a holder. If the patient makes strong expirations and in- 
spirations through the nostrils, many facts may be elicited 
in the examination, especially the presence of a polypus 
with a narrow base, allowing the growth to move in and out 
with the respiration, etc. It will generally be necessary to 
push the tip of the nose upward and backward, so as to 
place the nares in a position for better inspection. 



DISEASES OF THE MIDDLE EAR. 

ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 

This affection is an inflammation of the lining of the 
drum cavity and Eustachian tube, of an essentially catarrhal 



CAUSES OF ACUTE CATARRH OF THE TYMPANUM. 



137 



nature. That is, it is of the milder order of inflammations 
of mucous membranes, the products of which are only 
serum or mucus. The same inflammation intensified so as 
to produce a purulent discharge, is placed in the category 
of purulent inflammations. 

Acute catarrh of the tympanum shows comparatively 
little tendency to destroy tissue, as is the case in the puru- 
lent disease, and as a result, the membrana tympani is fre- 
quently not perforated, as is the rule in the other form. 
If the membrane is perforated, it is not likely to be the re- 
sult of ulceration, which might produce a large opening, 
as in the purulent form, but rather of pressure from inflam- 
matory products in the tympanum, and a fissure-like per- 
foration, which rapidly heals, is likely to be the result. 
Inflammatory proliferation is much more likely to result 
than disorganization. 

This affection is usually developed from some form of 
throat trouble, but it may also depend on causes located 
about the external ear. It may attack both ears simulta- 
neously, but is more likely to attack the second ear one or 
several days after the first. It may again attack one ear 
alone, but as the condition of the throat is usually at the 
bottom of the matter, sooner or later both ears are likely 
to be involved. 

The attack generally comes on towards evening or in the 
night, the symptoms subsiding by morning, to recur again 
on the next evening unless interrupted by treatment. Its 
tendency to return whenever there is exposure to cold, or 
when the patient has been irregular in his habits, is well 
enough known. This is one of its most serious features, 
and often leaves the patient in a state of incurable deafness, 
unless great care is taken to treat symptoms promptly as 
they arise. 

The subjective symptoms are as follows: In a given case 
there may be a sore throat that has existed for a few hours 
or days, when a painful sensation is felt in one side of the 
throat, on which there may have been the greatest amount 
of trouble, which passes up the Eustachian tube towards 
the ear. After a little time the ear may have a full or 
stuffed feeling, which may be converted into a violent 
throbbing pain. The voice of the patient will sound hol- 
low and out of pitch, the patient feeling it unpleasantly in 
the ear, for precisely the same reason that the tuning-fork 
on the teeth is heard better in the ear affected with middle- 



138 DISEASES OF THE EAR. 

ear disease. Dr. Sexton, of New York, has called this 
symptom autophony. 

The pain continues, in a severe case, until secretion is in- 
augurated or the membrane is perforated, when, with many 
premonitory loud crackling sounds, which may send sharp, 
darting pains through the ear, relief is experienced. I infer 
that the crackling sound depends on interchange of air be- 
tween the throat and the tympanum. In very mild cases, 
where there is scarcely any actual pain, this crackling is 
the most noticeable symptom of all. The Eustachian tube 
normally is nearly or quite closed in a state of quiescence, 
and by its valve-like faucial extremity resists to some ex- 
tent the passage of air from the throat to the tympanum. 
When in a catarrhal condition, if the inflammation be not 
too intense, there seems to be a relaxation of the tissue 
about the mouth of the tube, or the swelling of the lips of 
the tube prevents exact coaptation, and the consequence is 
that air is forced in or drawn out of the tympanum, causing 
this crackling sound. In other words, the tube is easily 
forced, and it will be found that Valsalva's operation is 
more readily performed than even in the normal state. 
Anything that condenses the air in the upper pharyngeal 
space will produce this symptom, as sneezing, coughing, 
blowing the nose, rapid expiration, especially if done 
through nostrils of narrowed calibre— which is likely to 
occur from the rhinitis so often accompanying this disease 
— eructations from the stomach, etc. When air is forced 
in with violence, much pain may be occasioned. On the 
other hand, rapid inspirations, especially if made through 
narrowed nostrils, rarefies the air in the upper pharynx, 
and air is drawn from the tympanum into the throat. 

When the auricle is pulled upon there is likely to be little 
or no pain, as the meatus and region about the concha are 
less frequently involved than in the severer forms of sup- 
purative disease. Movements of the jaws, deglutition, 
sneezing, coughing, or talking, are often painful. If there 
are severe throat complications, the swallowing of cold 
water may cause exquisite pain. Movements of the head 
from side to side are often painful. There may be tender- 
ness in the scalp, and pain in the side or back part of the 
head. Occasionally, in the severer forms of the disease, 
there may be pain and tenderness in the mastoid region. 
The pain in the ear may extend forward to the teeth, and 
indeed may be more intense there than in the ear, just as 



SUBJECTIVE SYMPTOMS OF ACUTE CATARRH. 1 39 

in carious and painful teeth the sensation may often be 
only in the ear. It is due to the fact that filaments of the 
fifth nerve are distributed both to the ear and teeth. In 
milder forms of the disease there may scarcely be any dis- 
agreeable symptoms except itching, deep in the meatus, 
which the patient often affects to relieve by scratching or 
thrusting his finger deeply into the ear, which frequently 
occasions throbbing and often results in much pain, with 
great aggravation of what were, mild symptoms. 

Sometimes the pain in the ear depends solely on the 
pressure of air upon the outer surface of the membrane, the 
result of an insufficient pressure upon the opposite side. 
This is brought about by closure of the Eustachian tube, 
the consequences of the disease, the residual air in the 
tympanum soon becoming absorbed. There is great rare- 
faction of the air, amounting almost to a vacuum, and the 
membrane pushes the ossicles sharply inward, and the 
labyrinth waters are compressed by the settling of the base 
of the stapes into the oval window. I once heard that 
Dr. T. G. Thomas was so interested in the result of an in- 
flation of the tympanum in the person of his coachman, 
that he related the case before his class. The man had a 
mild form of tubal catarrh, which caused great pain. This 
was instantaneously relieved by Politzer's inflation. This 
pressure, incident to a collapsed membrana tympani, some- 
times produces a feeling of fulness in the ear, difficult to 
diagnosticate from that of hyperaemia. 

Deafness. — In the outset, before hyperaemia becomes ex- 
cessive, and the parts are absolutely free from secretion, 
the ear being in a state in which irritation seems to pre- 
dominate over inflammation, the hearing may be morbidly 
acute. Very soon a slight diminution of hearing is observed, 
or it becomes so profound that loudly spoken words cannot 
be distinguished. The deafness results from the following 
conditions: hyperaemia of the tympanum, producing pres- 
sure upon every portion of the contents of the tympanum, 
impeding the vibrations of the membrana and ossicula. 
This congestion may also extend to the labyrinth and in- 
terfere with the function of the acousticus, and for the time 
cause true nervous deafness, which may be recognized by 
the tuning-fork. 

Again, after the stage of secretion commences, the tym- 
panum becomes more or less filled with the products of in- 
flammation, which obstruct the hearing by the retardation 



140 DISEASES OF THE EAR. 

of vibrations. Naturally, filling the tympanum full, with 
bulging of the membrane, would produce profound deaf- 
ness; but it has been found that a small amount of secretion 
may much diminish hearing. I once removed one or two 
drops of serum from the tympanum by paracentesis and 
inflation, and the hearing was astonishingly improved. I 
believe that the smallest amount of mucus resting on the 
round window, will interfere noticeably with the hearing, 
or any clogging of the movements of the base of the stapes 
by the same process will also much interrupt its function. 
Even if mucus covers the inner surface of the membrana 
tympani, and clings to the ossicles, there is interruption 
to free vibrations sufficient to cause deafness. There is 
another cause of deafness, more important than any I have 
mentioned — that is, the sinking of the membrana tympani, 
in consequence of closure of the Eustachian tube. As a 
result of this collapse, the membrana tympani is put upon 
the stretch, the ossicles are crowded together, the base of 
the stirrup is driven into the oval window, the labyrinth 
waters are pressed upon, and the membrane of the round 
window may be pressed towards the tympanum. 

Here are two causes of deafness: first, the interference of 
free vibrations of the apparatus of the middle ear by this 
pressure, and second, actual pressure upon the labyrinth. 
Whether this latter acts by pressure directly upon the 
nerve of hearing, or by interference to the conveying of the 
sonorous undulations incident to increased pressure upon 
the labyrinth waters, it is hard to say. In my observations 
on the tuning-fork and bone conduction, it will be seen 
that I incline mainly to the opinion that interference in the 
vibrations of the middle-ear mechanism is the principal 
factor in the causation of the deafness. The latter gen- 
erally comes on suddenly, the patient describing the ear as 
having all at once closed up. 

From the conditions just described, we have certain ex- 
tremely disagreeable symptoms, namely, tinnitus aurium, 
hearing one's own voice too distinctly, which may also have 
a hollow reverberating sound, a stuffed feeling, or a feeling 
as though the ear was filled with some foreign substance. 
The latter symptoms may point indifferently to engorge- 
ment of the tympanum or a sunken membrana tympani. 
Another symptom dependent on pressure is vertigo. It 
may be so great that the patient has fears of falling out of 
bed. 



OBJECTIVE SYMPTOMS OF ACUTE CATARRH. 141 

Frequently there is no fever, and again there may be a 
violent febrile movement. Sometimes delirium may be 
noticed, especially in young children. Many of the symp- 
toms simulate brain trouble. 

Objective Symptoms. — In the first instance, there is likely to 
be signs of catarrh of the pharynx, with or without pharyn- 
geal or laryngeal symptoms. The upper pharyngeal space 
is the one to critically examine; for the description of which 
see naso-pharyngeal conditions giving rise to ear trouble. 
Naturally the rhinoscope will be needed here, and other 
instruments for examining the Eustachian tube. Externally, 
the meatus may show few signs of disease, except being 
reddened perhaps, and scurfy. The speculum auris may 
elicit some tenderness. 

The membrana tympani is the important point of ob- 
servation. It is true there may be a catarrh of the tym- 
panum, without redness of the membrana tympani, provided 
it be sufficiently mild, but the membrane may show undue 
brightness of the light spot, from opacity of the mucous 
layer; hence the augmented reflection at the umbo. Be- 
sides, the membrana tympani will not present the normal 
pearly-gray translucency, but will look flat or opaque, and 
of a darkish hue. Where the membrana tympani has be- 
come sunken, there will be the following changes: the 
malleus handle will be too vertical, or too horizontal; it 
maybe drawn inward, giving it a foreshortened appearance, 
not approaching to the centre of the membrane, but to a 
point upward and generally backward. In consequence of 
chis movement the short process will be thrown outward, 
appearing too prominent. The light spot when present, 
will usually be too small; a better diagnostic, however, is a 
malposition of the reflex; it will present an acute angle 
with the anterior border of the malleus handle, or its angle 
may be too obtuse; it may be too near the centre of the 
membrana tympani, or be displaced towards the periphery. 
The folds of the membrana tympani may become greatly 
exaggerated, especially the anterior fold. The membrane 
may sometimes not be reddened at all. Again, where the 
mucous layer is intensely reddened, the membrana tympani 
will be more opaque, and when it still retains some trans- 
lucency in its outer layers, this color may shine through as 
a faint dusky red. 

The whole membrane may be congested so as to be com- 
lletely reddened, but not of the intense red color described 



142 



DISEASES OF THE EAR. 



in suppurative otitis. More likely, however, the redness 
may be seen about the short process; after a little, a streak 
of redness may be seen coursing down the malleus handle, 
from congestion of the manubrial plexus of vessels. With a 
greater degree of hyperaemia, vessels may be seen shooting 
from the periphery to join those of the manubrium, when the 
whole of the membrane may become reddened. It is quite 
easy to discern individual vessels. Be careful to discrimi- 
nate between the hyperaemia which is the result of disease, 
and that which is a consequence of traumatism. Rough 
handling of the ear in fixing the speculum or violent in- 
flation of the ear will cause considerable redness of the 
membrane. If a number of persons examine an ear with a 
pretty hot artificial light, some congestion probably will 
result; where a collection exists in the tympanum, the 
membrana tympani may bulge; if so, the protrusion will be 
generally found in the posterior superior quadrant and will 
seem to merge into the meatus; occasionally it may bulge 
in front as well, and the manubrium will seem to divide the 
membrane into two portions. If there is not too much 
congestion, and the outer layer is intact, a light reflex may 
be seen on the summit of the ectasia. 

Again, if there is a collection in the tympanum, with no 
change in the position of the membrana tympani, the light 
spot being opposite to an opaque fluid, will appear exces- 
sively bright and glassy. I have often diagnosticated fluid 
in the tympanum by this symptom alone. If the subject is 
not too old, nor has an excessively opaque membrana tym- 
pani, the fluid may be seen through the membrane. It will 
give the latter a darker hue, perhaps of a yellowish or green- 
ish cast. If there is considerable mobility of the fluid, its 
level may be changed by tilting the head forward or back- 
ward or cause it to disappear altogether by turning the head 
to the opposite side. If inflation is performed, the level of 
the fluid is changed, and often air-bubbles may be seen 
about the top of the fluid. 

By the use of Siegle's otoscope (see Index), a hint may be 
gained as to the presence of fluid in the tympanum. If the 
membrana tympani is pushed sharply in, the fluid will rise, 
or it will recede if the opposite movement is made. The 
malleus handle fails to make the normal lever-like move- 
ment when any considerable collection is present. In rare 
cases it may be possible to assert that the contents of the 
tympanum is mucus or blood, by its color, but none except 



THE DIAGNOSIS OF ACUTE CATARRH. 143 

experts can determine this. Sometimes the fact of fluid in 
the tympanum may be elicited by auscultation with the 
diagnosis tube; a moist rattle or click is heard instead of a 
dry one, and the bursting of air-bubbles in the tympanic 
fluid will yield a peculiar crepitating rale, which the sur- 
geon, after much practice, will be able to distinguish. 

The diagnosis of acute catarrh of the tympanum is some- 
times difficult. Very great pain, with speedy rupture of the 
membrana tympani and a purulent discharge, proves that 
we have the suppurative form. In the mild cases where 
there is little or no redness of the membrana tympani, with 
the presence possibly of carious teeth, there will be real 
difficulty in determining whether the trouble comes from the 
ear or the teeth; sometimes it comes from both. The use of 
the tuning-fork, testing the hearing by other means, and 
contrasting the amount of hearing before and after infla- 
tion, making careful observation as to the presence of fluid 
in the tympanum, etc., will determine the diagnosis. Where 
there has been an old catarrh with impairment of the hear- 
ing, but which is improved by inflation, it is very difficult 
to tell whether it is the teeth or the ear which causes the 
disturbance. I have before now been in doubt, and have 
caused the teeth to be attended to, and the pain has disap- 
peared. The pain from the ear is often of a neuralgic 
character, and may be indifferently in the head or ear, and 
will sometimes mislead us. In such cases it may be found 
that the pain does not follow the laws of a neuralgia, and 
some disturbance in the function of the ear maybe noted. 

In the adult there need be no trouble about mistaking 
brain symptoms for ear symptoms. In children there is 
much greater difficulty in diagnosis on account of absence 
of rational signs. I have, in the person of my own children, 
made this observation. A child would be restless most of 
the night, and no cause could be assigned for the trouble, 
when in the morning a discharge from the ear revealed the 
correct explanation. I think we are too loth to examine 
carefully the membranes of children. In a case of consid- 
erable pain in the young subject, naturally we look to the 
bowels or head, or possibly the teeth, for the explanation ; 
but if we always have in our mind a suspicion that it may 
be the ear which causes it, we shall be sufficiently on our 
guard. In a suspected case, if we do not object to doing it, 
a hint may be gained by the sense of smell ; if there be the 
slightest discharge, its peculiar odor will at once direct at- 



144 DISEASES OF THE EAR. 

tention to a diseased condition. A little harsh handling of 
the ear may elicit tenderness, pointing to disease. If the 
patient has throat trouble of any kind, or presents the 
conditions which may give rise to ear trouble, we are put 
upon our guard. A little sufferer from ear pain may put 
the hand to the head and indicate the location of the trouble. 

In the pneumonia of children, ear complications frequently 
arise, which may give us a hint to inspect the ear when ne- 
cessary. In examining a suspected ear in a child, even though 
we find no redness, there may be retraction of the malleus 
handle, which in children is a more conspicuous symptom 
than in the adult. We inflate by Politzer's method, and the 
membrana tympani is restored to a more normal position, 
and the patient may be relieved from suffering, when the 
diagnosis is pretty well determined. Other means for the 
relief of pain in the ear may be used, and if they succeed, 
the fact points to the probability of ear trouble as the cause 
of the pain. 

The causes of acute catarrh of the tympanum are so simi- 
lar to those of the purulent form that I hardly need go 
into detail. 

The first important factor is the inflamed throat. This 
may be excited by any catarrhal influence whatever. 

The exanthemata are always liable to result in ear trouble 
consequent on the throat complication. Croup and diph- 
theria produce conditions in the throat liable to cause ear 
involvement. Some forms of fever may be accompanied by 
throat symptoms, which occasionally result in ear compli- 
cations. 

Pneumonia and pleurisy are often accompanied by acute 
ear troubles, which depend, first, on the accompanying 
throat disease, and second, upon the violent interchange 
of air between the throat and ear cavity, consequent on the 
rapid respiration incident to these diseases. This has been 
already explained. Besides producing labyrinth trouble, 
syphilis may, by its somewhat constant throat symptoms, 
develop middle-ear disease, without necessarily going deeper. 
Bright's disease, through defective bloodvessels, may result 
in middle-ear trouble; but hemorrhagic disease through 
rupture of the vessels is more likely to occur. Hooping- 
cough, by violent inflation of the ear during a paroxysm of 
coughing, sometimes ruptures the membrana tympani; but 
the violent inflation itself is sufficient to excite inflamma- 
tion. Politzer's inflation may sometimes excite a catarrh 



CAUSES OF ACUTE CATARRH OF THE TYMPANUM. 



J 45 



of the tympanum. Tuberculous patients are strongly in- 
clined to catarrh of the tympanum, in consequence of the 
extension of some form of bronchial or naso-pharyngeal 
catarrh, to which they are so subject, to the ear, through 
the Eustachian tube. Tuberculous matter (a cheesy ma- 
terial) in the tympanum often results in middle-ear catarrh. 

Sea-bathing, as in the case of suppurative trouble, excites 
this affection in several ways. Breakers striking the ear 
may rupture the membrane, or even if it is not ruptured, 
the cold water enters the meatus, which is enough to excite 
inflammation. Again, the patient may take the water into 
the mouth, and in the agitation and excitement he may 
attempt imperfectly to swallow it, by which means some of 
it is forced into the tympanum and excites inflammation. 
Sometimes, in swimming, a wave dashes the water into the 
nostrils, which, in the strangling efforts to remove it, is often 
forced into the ears. The nasal douche has inflicted many 
aural catarrhs upon those who use it, and I have abandoned 
it almost altogether. Even snuffing up water into the nos- 
trils from the palm of the hand, has been known to pass 
into the ears and do harm. In my own practice of sending 
a few drops of salt and water into the nostrils by means of 
an atropia-dropper, it has occasionally passed into the ears, 
with deleterious effects. 

The irritation of carious teeth, or even the advent of the 
wisdom tooth, has been known to excite an otitis. Teeth- 
ing in children has long been asserted to be a cause of otitis, 
and I do not doubt that it is — less frequently, however, than 
it is asserted to be. The cold pack in water cures, or the 
Turkish and Russian baths, have been known to excite this 
disease. As aural catarrh is more prevalent in the spring 
and fall, when the air is changeable, we readily infer that 
catarrhal influences are at work. Exposing the ear to a 
draught of air in any manner may provoke a catarrhal attack. 
Taking cold, even though it be very slight, may, in those 
so predisposed, go to the ear. Another fact is of great in- 
terest — that the patient is much more likely to " take cold " 
when depressed, from any cause whatever. Many patients 
require cotton in the ears during the winter to keep them 
from becoming inflamed and painful. 

Prog?iosis. — As a rule, patients make a good recovery. As 
has been previously hinted, there is little tendency to de- 
struction of tissue. If the membrana tympani ruptures, 
there is usually no loss of substance : only a fissure, which 



I46 DISEASES OF THE EAR. 

rapidly closes. I have seen such fissures heal in one or two 
days, although as many weeks may be occupied in repair. 
The favorable prognosis often turns on the short duration 
of the disease; for, if it is continued a certain time, changes 
of a proliferous nature are likely to occur. If the cavity 
has been completely filled with secretion and there has been 
great pressure, not relieved by rupture of the membrana 
tympani or evacuation from the Eustachian tube, the mem- 
branes of the round or oval windows may rupture, and 
serious labyrinthine disease result. The mastoid cells may 
be filled with the tympanal secretion, and take on true 
mastoid cell disease. Mastoid periostitis is not as likely to 
occur. The result to be greatly feared in this disease is the 
obstinate catarrh of the pharynx, which so frequently ac- 
companies the affection. Especially is this the case with 
those having struma or tuberculosis, where it sometimes 
seems impossible to overcome the difficulty. The same is 
true of many weakly, or at least sensitive, people, whose 
mucous membranes are constantly irritated by the harsh- 
ness of the air in many parts of this country, and the only 
means of relief seems to be the selection of an atmosphere 
congenial to the patient. I have seen a patient with pain 
in the ear, tinnitus, etc., changed to a better atmosphere, 
when in a single day all the symptoms disappeared. 

I infer that while a patient has a catarrh in the neigh- 
borhood of the Eustachian tubes he is always liable to ear 
complications. One great danger is, that in the frequent 
relapses, which do not present very noticeable symptoms 
and consequently the attention of the patient is not suffi- 
ciently drawn towards them, that treatment will be neglected, 
at a period when great deafness may result. I once had a 
catarrh patient go into the country for two weeks in mid- 
winter, when he had a slight relapse of his symptoms, which 
were not treated until his return. The hearing had been 
fifteen inches for the watch, and it went down to three or 
four inches, from which I could never raise it. 

In consequence of the proliferating changes in the Eus- 
tachian tube the latter is less under the control of the tubal 
muscles, and the patient may complain of crackling in the 
ears, due to the fact that the tube is frequently forced. 
Again, there is less of that opening and closing of the tube 
which in a normal state maintains exactly the proper 
amount of air in the tympanum. If the tube be perma- 
nently narrowed, on the recurrence of a subsequent catarrh 



PROGNOSIS OF ACUTE CATARRH OF THE TYMPANUM. 147 

it is more readily closed than it would have been had it 
been of normal calibre. This symptom may exhibit itself 
on very slight changes in the weather. In children, who have 
an ample Eustachian tube, it is less likely to occur. This 
condition may even be a source of safety where there are 
collections in the tympanum, which may have no other 
means of outlet, thereby possibly preventing grave compli- 
cations from the effects of confined matter in the tympanum. 
The altered and often sclerosed condition of the tympanal 
lining, I have often thought, acted as an exciting cause to 
future attacks, somewhat as the cicatricial changes in gra- 
nular conjunctiva predispose to relapses. 

The hearing ought to be perfectly restored. If the disease 
has continued long enough to thicken the tympanal lining, 
there will be some diminution in the sharpness of the hear- 
ing. A more important state is the collapsed membrana 
tympani. If the latter has remained in this condition for a 
few weeks only, it may never return to a normal position. 
It seems as though the membrana tympani, by its collapsed 
state, had become stretched, so as to increase its super- 
ficial area, when a sunken or cup-shaped condition was the 
more natural. I have seen patients with an abnormally 
patulous tube and sunken membrana tympani, who could 
restore the membrane by inflation, with improvement to 
the hearing, momentarily, but on the first act of swallowing 
it was thrown back to the old condition, the membrane ap- 
parently remaining in proper position only when actually 
pushed outward by the intra-tympanal air-pressure. 

The fact that patients subject to catarrhal otitis often 
have an ancestry with the same tendency points to heredity. 
I am sure that the catarrhal and the rheumatic diatheses 
often seem to be a matter of heredity, and these affections 
are quite sufficient to cause ear trouble. Tinnitis aurium 
usually disappears, but it is not certain to do so, the 
catarrh sometimes setting in motion a tinnitus which may con- 
tinue a part or the whole of the time during the remainder of 
the patient's life. 

Treatment. — Although the hypercemia is not as intense as 
in the suppurative variety, it is still quite decided in some 
cases, and results in much pain and throbbing, and a sense 
of fulness in the ears. From one to three leeches may be 
applied to the orifice of the meatus, preferably to the pos- 
terior face of the tragus. The objection to applying them 
to the concha is, that they sometimes cause abscesses and 



148 DISEASES OF THE EAR. 

erysipelas. There is no question, from my own experience, 
and from that of many others, that in this location, deple- 
tion accomplishes much more than when applied elsewhere. 
After the leech has fallen off, encourage bleeding for one 
or two hours by bathing with warm water. In properly 
selected cases the relief to pain and the feeling of fulness 
is most extraordinary. In other cases the pain is aggra- 
vated by the leech, a dull, dragging pain being substituted 
for the former kind of pain. This being the case, I at once 
give large doses of morphia either hypodermically or other- 
wise. 

It is worthy of remark, that where the pain depends on a 
distended tympanum from inflammatory products the leech 
will not relieve. In milder cases warm or hot applications 
to the ear are very serviceable. The most elegant method 
is to place warm or hot water into a rubber bag and lay it 
on the ear. The temperature should be regulated so as to 
give the patient the greatest relief. Very warm water will 
sometimes aggravate, so will too cold water. Latterly, it 
has been the practice of some to use cold or iced water. I 
can imagine it to do good in some cases of very excessive in- 
flammation, of the sthenic variety, but I am, on the whole, 
timid about recommending cold to the ear. If it relieves 
the pain and throbbing, and there is not directly afterwards 
a violent accession of inflammation, it is likely to be suc- 
cessful. I may be superstitious about the action of cold 
on the ear. Common salt heated and placed in a bag is a 
good application to the ear, or any dry agent susceptible of 
retaining heat is serviceable. A bottle of hot water wrapped 
in a napkin, with the ear laid against it, is an inexpensive 
and easily applied method. 

Moist applications, from their macerating tendency, 
should be objected to, unless used for only a limited period. 
Even a hot flaxseed poultice may be applied for a brief 
period. The old-fashioned mode of applying the core of a 
roasted onion by its conical extremity to the meatus may 
properly be recommended. A better plan for moist appli- 
cations is the direct use of warm water to the meatus: fill 
the latter with warm water, turn the head to the opposite 
side, and let it remain for half an hour. A better plan still 
is to allow warm water to run into the ear from Clark's 
aural douche. (See Index.) This maybe continued twenty 
or thirty minutes at a time, desisting when it relieves or no 
longer feels pleasant to the patient. This method is very 



ACUTE CATARRH OF THE TYMPANUM. I 5 I 

the attempt, but let it be done gently. At first it may oc- 
casion sharp pain, but usually it gives great relief. It may 
be done by Politzer's method rather than by the catheter, as 
the latter may irritate or lacerate the inflamed throat and do 
mischief. The rule, then, is, inflate very gently at first, and 
if it acts well continue it, and if there is too much pain, 
desist. The inflation should be done sufficiently to elevate 
the hearing to the highest attainable point. If this point 
is passed, and the hearing diminished, and tinnitus and 
pain results, then direct the patient to hold his nose and 
swallow several times; this will empty the tympanum of 
excess of air, and again restore the hearing, provided the 
tube is not too swollen to open upon muscular contraction. 
The latter not being the case, air will be confined in the 
tympanum, and may for a while aggravate the symptoms. 
This is one of the objectionable features of inflation. It 




JMYNDERS&CO, 
Fig. 42(5.— Pomeroy's Post Nasal Syringe. 

is a good rule to do nothing to the patient which may oc- 
casion any throbbing or pain in the ear. Manipulations 
which are not altogether gentle, or even the mildest syring- 
ing, may do harm by adding to the existing hypersemia. 
Even the leeching must be done by a careful hand, for 
rough manipulations have sometimes caused a return of 
the pain which the leech had previously relieved. 

The inflation for the restoration of the collapsed drum- 
head is only a temporary measure, and the tubal catarrh, 
which is the cause of the trouble, should be treated. Some- 
times a case may be so mild, and show no symptoms of 
disease except in the Eustachian tube, that the diagnosis 
of tubal catarrh may very properly be made. This condi- 
tion may be met in the following manner: simple salt and 
water warmed, and of the strength of a drachm to the pint, 
may in mild cases suffice. It may be thrown behind the 
velum by means of a spray-producer or the posterior nasal 
syringe. I prefer the one devised by myself, which has a 
tip separated from the syringe by a rubber tube (see Fig. 
10 



152 DISEASES OF THE EAR. 

42 b). 1 use my own hard-rubber spray instrument ; any 
other may be used ; the glass instruments are the best, but 
they often break. Not more than half an ounce or an 
ounce of the salt and water could be injected ; do it very 
gently, instructing the patient to remove it at once by ex- 
pectoration. The dropping tube may be used for this pur- 
pose, the fluid being thrown into the anterior nares ; but 
in all these applications do not allow the patient to be 
frightened or agitated, for he may cough, sneeze, or swallow, 
which may cause the fluid to enter the tympanum. 

Some years since, while in Vienna, I saw Dr. Adam Polit- 
zer using for this purpose a little earthenware vessel having 
a nozzle which fitted the nostril, similar to our sick-feeder, 
which he used by pouring the fluid into the throat. When 
this medication is insufficient, chlorate of potash in satu- 
rated solution may be used, or carbolic acid, one drachm 
to the pint of water. It may be necessary to give the 
patient general treatment for naso-pharyngeal catarrh. 

Where more energetic measures are needed, I employ 
the nitrate of silver. It may be used with the posterior 
nasal syringe or spray instrument, the Eustachian catheter, 
or my own faucial catheter. The strength may be from a 
few grains to the ounce, to a one-hundred-grain solution. 
When a drop or two is used by either of the catheters, or 
the spray instrument is used, a much stronger solution will 
be borne. In using the posterior nasal syringe it is a good 
plan to draw up five or ten drops of a ten or twenty grain 
solution, and force it in strongly enough to cause a coarse 
spray to be produced. If much pain results, throw T in two 
or three drachms of salt water, which frequently, but not 
always, gives surprising relief. If the solution has been 
too strong, the tube may swell, and for two or three days 
become somewhat impervious. If a prolonged soreness is 
left in the throat, the remedy has been too severe. There 
ought to be a feeling of relief from the application after a 
few minutes or an hour or two. Tincture of iodine may 
sometimes be used, but only one to three or four drops 
should be thrown up at a time. It may be diluted with al- 
cohol if necessary; it is sometimes painful. Chloride of 
zinc acts somewhat like nitrate of silver, but it is occasion- 
ally a harsh remedy. Many other astringents may be used, 
being careful to reject any that act badly. It is not possi- 
ble to determine beforehand which remedy will be the 
most beneficial. Often sore and painful tracts of redness 



ACUTE CATARRH OF THE TYMPANUM. 



53 



with pain on deglutition may be observed in the pharynx. 
The best plan is to touch these with a twenty to forty grain 
solution of nitrate of silver, using cotton on a holder for the 
purpose. Although it is a harsh remedy, I know of nothing 
which will so soon abolish the pain and inflammation. 

Often at the outset of an acute catarrh with pain in one 
side of the throat which shows a tendency to travel up the 
Eustachian tube to the ear, the whole process may be ar- 
rested at once. A patient under my care was treated by 
mild remedies without effect. On returning home after one 




Fig. 43.— Apparatus for Generating Steam for Intra-Tympanal Injection. 

of these applications, the pain was aggravated; it could be 
followed up the Eustachian tube to the tympanum; the 
latter began to throb painfully, and in desperation I poured 
a freshly made forty-grain solution of nitrate of silver into 
a hard-rubber spray instrument, and threw up an abund- 
ant spray for two or three seconds behind the velum, point- 
ing it towards the Eustachian tube. It caused considera- 
ble pain for fifteen or twenty minutes, but the symptoms 
wholly disappeared, and no further treatment was neces- 
sary. A somewhat threatening attack was evidently wholly 
aborted. 

I am aware that nitrate of silver often acts injuriously, 



154 



DISEASES OF THE EAR. 



exciting severe pain, and causing much soreness of the 
parts, which may remain for days or weeks afterwards. 
The question is to select the cases in which it is likely to 
act favorably. The above indication of pain and localized 
soreness I believe to be favorable to the remedial action of 
nitrate of silver. I have in some instances applied a strong 
solution of the arg. nit. to a painful and hot locality in the 
upper part of the pharynx, the result of inflammation, 
where it produced no pain whatever, but actually felt cool, 
and afforded the most grateful relief. The principal 
trouble seems to be that the patient does not in some cases 
appear to react successfully from the application. Some- 
times steam injected against the mouth of the tube, and 
often into the tympanum, acts well in reducing the en- 
gorgement of the Eustachian tube (see Fig. 43). The hard- 




Fig. 44.— Pomeroy's Catheter Holder. 

rubber catheter should be used for this purpose, as the me- 
tallic instrument becomes too much heated; it requires to 
be fixed in position by the catheter holder; I believe my 
own instrument is a sufficiently good one for the purpose 
(see Fig. 44). Do not prolong the sitting beyond four or 
five minutes, giving a few puffs, and then waiting a half 
minute, and then repeat. The first effect will be to congest 
the lining of the tube, but subsequently the hyperaemia 
will be diminished. I would not make applications to the 
throat oftener than once in two days, unless it be some 
remedy of the milder variety, like carbolic acid, a drachm 
to the pint; this may be used, perhaps a little diluted, in 



ACUTE CATARRH OF THE TYMPANUM. 1 55 

the upper pharnyx with a Davidson spray instrument (see Fig. 
45) by the patient himself two or three times a day, but avoid any 
unpleasant irritation of the part. I have sometimes observed that 
remedies applied to the Eustachian tube render it too pervious, 
so that interchange of air between the throat and tympanum 
become unpleasantly frequent. 

Prophylaxis. — Inasmuch as this disease depends largely upon 
the habits of the patient and climatic influences, much maybe 
done to prevent recurring attacks. Everything that tends to ex- 
cite a " cold " should be scrupulously avoided. It takes years of 
experience to live wisely in this respect ; it is only those who be- 
come somewhat venerable in years who may be seen carrying an 
umbrella almost habitually, with an overcoat on the arm, or actu- 
ally wearing it, and with properly shod feet, who regulate the tem- 
perature of the body as carefully as a chemist would a compound. 
Patients subject to aural catarrh become surprisingly sensitive to 
any lowering of the temperature. I have known such to observe 
the direction of a draught by a pain, or an unpleasant feeling in 
the ear, when no other signs of its presence existed. They seem to 




J. REYXDERS—CO 

Fig. 45.— Davidson Spray Instrument. 

be as sensitive to atmospheric changes as an habitually rheumatic 
patient. Riding in the wind is often extremely pernicious, and the 
patient should have the ears protected by cotton-wool in the 
meatus, or some other mode of protection. Wet or damp feet or 
damp clothing must be avoided ; or on returning from a ride or 
walk everything damp should be removed and dry clothes substi- 
tuted. The action of peculiar atmospheres has already been 
alluded to. I believe nothing exerts so strong an influence on 
the well-being of a catarrhal patient as congenial air. It 
would seem almost as important as in the case of an asth- 



156 DISEASES OF THE EAR. 

matic patient. If one remains in an atmosphere which 
constantly congests the lining of his pharynx and Eustach- 
ian tubes, it is well-nigh impossible for him to do well; he 
is likely to go on adding to his deafness by successive at- 
tacks, until great hardness of hearing may result. An- 
other important indication is to cultivate as vigorous a 
state of the general health as is possible, thus enabling the 
patient to resist the ill effects of our climate. 

I do not believe in avoiding the out-door air to prevent 
taking cold. I have noticed that our stage-drivers rarely 
suffer from catarrhal affections, notwithstanding they are 
on their boxes driving, sixteen or eighteen hours a day, 
and exposed to all weathers. Their vigorous physiques 
resist the catarrhal influences, and this state has been 
brought about by constantly being in the open air. Care- 
ful regulation of all the habits is a more important matter 
than is usually supposed. 

Tuberculous or strumous patients may require, in addi- 
tion to a nourishing diet, stimulants and cod-liver oil, the 
latter in some form of emulsion. Excessive fatigue or ex- 
haustion should be avoided, as diminishing the power of 
the constitution to resist the effects of cold. I know a gen- 
tleman who will never admit that he has overworked or 
become exhausted, but he suffers frequently from "a cold " 
which seems always to attack him in times of depression. 
Even in midsummer the inclement atmosphere exists. I 
have observed that those who go into the country suffer es- 
pecially. The middays are excessively warm, but the even- 
ings often are cold, the temperature after sunset going 
down very suddenly, and blankets may be in requisition. 

It is advisable to direct the patient to always breathe 
through the nostrils when possible. One of the best plans 
for keeping the nostrils free is to constantly breathe 
through them, besides the favorable influence resulting 
from a current of air passing across the faucial orifices of 
the Eustachian tubes. This matter will be developed more 
fully under the head of naso-pharyngeal catarrh, etc. If 
the mouth only is used in breathing, air is insufficiently 
warmed, and it irritates the pharynx. Sometimes I advise 
a respirator to be worn over the mouth so that the air may 
be rendered less irritating to the throat. From what has 
been said it would seem to be almost a fine art to protect 
the system properly from our variable and inclement at- 
mosphere. 



CHRONIC CATARRH OF THE TYMPANUM. 1 57 

Co?istitutional treatment has already been hinted at in the 
previous topic. To those who accuse us of treating dis- 
ease locally and depending on it, I would say that I am 
most heartily in favor of doing anything that benefits the 
general health of the patient. Some of our therapeutic 
friends will tell us that a large dose of quinia acts favora- 
bly in a commencing sore throat — may break it up, in short. 
Tr. aconit. rad. is also given for the same purpose. Others 
take pleasure in aborting threatening symptoms by a large 
dose of spts. vin. gal., or something of the kind. In 
the outset of an attack it may be broken up by somewhat 
prolonged and excessive perspiration in bed, with or with- 
out a cathartic dose. A warm foot-bath is a very harmless 
and effective mode of inducing perspiration, or bottles of 
hot water may be placed at the feet and on either side of 
the patient to accomplish the same purpose. If there be 
no undue obstruction in the bowels, a large dose of morphia 
may suddenly abort a threatening attack. A full dose of 
tr. of guaiac may sometimes be very serviceable. 



CHRONIC CATARRHAL INFLAMMATION OF THE TYMPANUM. 

Most of the works on diseases of the ear have a chapter 
on sub-acute catarrh of the tympanum. As this affection 
is one intermediate between the acute and chronic affec- 
tions, it seems hardly necessary to elevate it into a distinct 
topic. Neither shall I make a separate heading for " pro- 
liferous" inflammation, "dry catarrh" or " moist catarrh," 
holding firmly to the opinion that these and all other 
manifestations of this disease are but the results of an in- 
flammation which at different stages, and modified possibly 
by constitutional peculiarities, produces the peculiar prod- 
ucts of inflammation characterizing this disease in its 
manifold developments. 

I believe for the most part that the peculiar quality of 
the inflammation found in the upper pharyngeal space is 
repeated in the ear: if there is a moist throat the tympanum 
is likely to be moist, and where there is a pharyngitis sicca, 
with a dry shining mucous membrane, a similar condition 
exists in the middle ear. It will be inferred from this that 
I hold to the view that most of these affections of the 
middle ear depend on a throat trouble, whether past or 
present. 



158 DISEASES OF THE EAR. 

It may be stated here, that the ear affection is not usually 
as far advanced in its development as that of the throat. 

Course. — The most frequent manifestation of this disease 
is seen in subjects who have had an acute affection of the 
tympanum, be it catarrhal or suppurative, which has failed 
to undergo resolution, owing to neglect of treatment or 
constitutional peculiarities. This statement is true in a 
much larger sense than would at first appear. The slight- 
est cold that obstructs the Eustachian tubes and "stops 
up" the ears is, strictly speaking, an acute catarrh, and it 
is from these attacks that the foundation possibly may be 
laid for a serious chronic affection of the middle ear. I feel 
some doubt as to whether this affection ever commences as 
a chronic catarrh. I am well aware that many elderly 
people are found to have a considerable degree of deafness, 
which must have been of long standing, but who will 
stoutly persist that they never have had symptoms pointing 
to acute disease of the ear. This we may readily believe to 
be a conscientious statement, but not necessarily a true one. 

The normal hearing is quite in excess of actual needs, and 
much of it may be lost without exciting the notice of the 
patient, unless he be unusually observing. It has been 
stated that many of these cases were unconnected with 
throat troubles, present or past. This is a statement 
impossible to prove, and the probabilities are against it. 

When we reflect that a catarrh of the upper pharynx 
may be sufficient to obstruct the Eustachian tubes, and 
exhibit so few symptoms of throat trouble that the most 
expert surgeon may overlook it, and the patient himself be 
unconscious of its presence, or that a catarrh may have been 
cured before serious ear trouble made its appearance, it 
will be seen how difficult it would be to substantiate such 
statements. I do not forget that a few patients take on 
ear trouble from influences acting in the direction of the 
meatus auditorious externus, and naturally throat compli- 
cations would be likely to be absent. 

This disease is perhaps the most dangerous to the hear- 
ing of any, except certain forms of labyrinth disease. As 
its insidious beginnings escape the notice of the patient, or 
at least fail to excite his apprehensions, much valuable 
time may be lost before treatment is commenced. It will 
be subsequently seen that in the later developments of this 
disease changes have taken place which are partially or 
wholly irreparable. 



CHRONIC CATARRH OF THE TYMPANUM. 159 

I do not know of any instance where a more unreasonable 
demand is made on a surgeon than when he is expected to 
cure chronic catarrh of many years' duration. As well 
might you expect to cure a man with disorganized kidneys, 
liver, or lungs. The deafness varies from very slight lower- 
ing of the hearing to that which is so profound as not to 
admit of hearing the loudest conversation. In the latter 
instance the disease has extended to the labyrinth, and bone 
conduction may be weakened or abolished. The most 
distressing and discouraging form of tinnitus aurium 
frequently accompanies this form of otitis. When this 
disease has produced profound deafness with tormenting 
tinnitus, we have about as unhappy a person as can well be 
imagined. These patients are full of jealousies, often 
imagining that people are talking ill of them, or exciting a 
laugh at their expense. Besides this, tinnitus sometimes 
becomes almost unendurable, and cases are on record 
where its victims in moments of desperation have sought 
relief in suicide. 

In marked contrast are the serene and kindly faces of the 
totally blind. 

Causes. — From what has preceded it will be seen that 
whatever causes an acute inflammation of the drum cavi- 
ties also is a pathogenetic factor in developing this affec- 
tion. The often-repeated " colds" so prevalent in this 
climate, which usually act through the throat and Eustach- 
ian tubes, are a frequent cause. 

Much has recently been written about the deafness of 
railway engineers, boiler-makers, and ship-calkers, which 
was formerly regarded rather as an affection of the laby- 
rinth than of the middle ear. Later investigations, how- 
ever, among which I may mention those of Dr. Holt, of 
Portland, Maine, point to the fact of middle-ear trouble as 
being the principal earlier lesion, followed subsequently 
by labyrinth trouble, the tuning-fork apparently proving 
the absence of nerve complications in a large number of 
the more recent cases. The explanation of boiler-makers' 
deafness seems to be twofold: first, the fact of exposure to 
draughts while heated and perspiring; and second, the vio- 
lent vibrations of the middle-ear mechanism inducing a low 
form of inflammation of the tympanum, which results in 
great thickening of the parts. In ship-calkers, the obser- 
vation was made that the ear next to the ship, and conse- 
quently receiving the more powerful concussions, became 



l6o DISEASES OF THE EAR. 

deaf, while the other ear, for a time at least, was unaf- 
fected. Here the concussion had mainly to do with the 
causation of the deafness. This also depended on middle- 
ear trouble. In railway engineers, as in boiler-makers, a 
twofold cause seems to operate. 

It is frequently the case that an engineer on a train run- 
ning 40 or 50 miles an hour is on the lookout without any 
protection from the powerful current of air engendered by 
the rapid motion of the train. The noise, of course, is of 
the harshest variety. 

A distinguished member of our profession in New York 
has been in the habit of riding daily during the warm sea- 
son to his country seat, in the steam cars. One day I no- 
ticed that he held his hand over one ear. He explained 
that he had deafness of the opposite ear from exposure to 
the rattling noises incident to railway travel, especially 
when going through tunnels at a rapid rate of speed. The 
affected ear was next to the open window. In this in- 
stance, again, we have the two factors — the draught of air 
from the open window and the concussion from the loud 
noises. It is no mystery that these patients subsequently 
take on labyrinth trouble, as this has become sufficiently 
well known to be a consequence of very chronic catarrhal 
inflammations. Gestation sometimes conduces to chronic 
aural catarrh. With each recurrence of gestation an ac- 
cession to the deafness results, and the patient ultimately 
becomes quite hard of hearing. 

It is worthy of note that strumous and tuberculous sub- 
jects incline to chronic aural catarrh. 

Constitutional syphilis, either acquired or hereditary, 
predisposes to catarrhal otitis. I believe that the rheu- 
matic diathesis, in many instances, has much to do with 
the obstinate character of this affection; the rheumatic in- 
flammation, according to its well-known predilection for 
fibrous tissues, finding a lodgment in the muco-periosteal 
lining of the drum. All possible unhygienic influences 
enter into the causation of this affection, as well as de- 
pressed vital energy, from any cause whatever. 

Subjective Symptoms. — The earliest and most important 
symptoms are deafness and tinnitus. As the hearing is 
normally much in excess, a portion may be lost without at- 
tracting the patient's notice. As a rule, the disease com- 
mences in one ear, and this may become profoundly deaf 
without the patient's being conscious of the loss, as the 






SUBJECTIVE SYMPTOMS OF CHRONIC CATARRH. l6l 

fellow-ear may do duty for both. Subsequently, however, 
the opposite ear will become involved. The deafness may 
come on suddenly if the Eustachian tube is closed, but if 
not, it may develop very gradually. I have noticed elderly 
people, with a hearing distance of 2 or 3 inches for the 
watch, who were hardly aware that they had become hard 
of hearing, and never had noticed any trouble with their 
ears. It frequently is the case that the voice or musical 
tones are much better heard than the watch. The deafness 
may be very slight indeed at first, but subsequently the 
profoundest deafness with labyrinthine complications may 
result. If there is moist instead of dry catarrh, the hear- 
ing will vary with the weather, being better in cold dry 
weather than in cold moist weather or in very hot weather — 
that is, when the mucous lining of the Eustachian tube and 
tympanum become more congested, or secrete more freely. 
In the dry variety the hearing varies in this wise: it be- 
comes a tiresome muscular effort for the patient to hear, 
as the contractions of the muscles of the tympanum in the 
accommodation of the ear are impeded by the thickening 
and rigidity of the tissues, and the consequent immobility 
of the middle-ear mechanism, and also by the diminished 
power of the tensor tympani and stapedius muscles them- 
selves, owing to structural changes, such as atrophy of 
muscle fibres, fatty or calcific degenerations, etc. In this 
case the patient hears worse when fatigued, or after hav- 
ing lost sleep, or suffered any hardship. This class of pa- 
tients will often present a variety of symptoms simulating 
those of brain lesions. 

Tinnitus aurium may be the first symptom noticed, or it 
may be absent for some time, but it is nearly always pres- 
ent. A buzzing noise in the ear may first call attention to 
beginning trouble. I have observed tinnitus in a case where 
there were no middle ear symptoms, and the hearing was 
perfect as far as moderately careful tests went. This noise 
in the ear is the great opprobium of the aural surgeon. It 
may continue through a lifetime, being either constant or oc- 
casional. In some cases it seems, after a few years, when the 
ear is nearly or quite spoiled, to entirely disappear; but 
this is somewhat exceptional. Again, it may only give the 
patient trouble when he has a cold or during a damp period, 
when the lining of the Eustachian tubes and tympani be- 
come congested. Anything which congests the parts tends 
to produce it; a full meal, especially if stimulants are used, 



l62 DISEASES OF THE EAR. 

may develop it. It is more likely to come on in the after 
part of the day, when the patient is fatigued and the blood 
mounts up to the head. Any unusual exertion is likely to 
produce it, especially public speaking. The supine position 
in sleeping, by increasing the hyperemia of the parts, is 
a factor in exciting it. The quietness of the night, how- 
ever, probably may permit the patient to notice a sound in 
the ear of which he was not conscious amid the noises of 
the daytime. 

The deafness may be nearly cured, but still the tinni- 
tus may remain. A close or overheated room, or an insuffi- 
ciently ventilated sleeping-room, may re-excite tinnitus. 

Pain is not a very frequent symptom, and is not usually 
intense. Where the Eustachian tube is closed and the mem- 
brana tympani presses on the fluids of the labyrinth it may 
be quite intense, and may extend to the side of the head. 
Whenever the patient takes cold and has a relapse there 
may be pain. Some patients are so sensitive that they 
must wear cotton in the ears most of the time to prevent 
the wind or cold atmosphere from being painful to them. 
If you shout into the ear of a patient who is pretty deaf, he 
will sometimes start back much disturbed, as the concussion 
of the loud noise has been painful to him, there often being 
a certain amount of hypersethesia of the nerve. I have 
noticed patients who were " run down" or depressed from 
any cause who would develop a pain in the ear as one of 
the symptoms of this condition. 

It is a well-known fact that carious teeth will cause pain 
in the ear. The mental processes are often affected in this 
disease, especially when pressure is made on the fluids of 
the labyrinth or on the brain. In such a. case the memory 
is weakened; the patient fails to grasp ideas and to main- 
tain a consecutive train of thought. The mind seems 
easily fatigued, and the patient may be unable to do as 
much mental labor as formerly. He is often irritable 
and filled with forebodings, and is low-spirited. The 
intra-labyrinthine pressure will often seem to the patient 
as though there were actual pressure on the brain, and 
often give him the sensation of being in motion. Ver- 
tigo and vomiting sometimes also result from this con- 
dition. The pressure is more likely to be brought about 
where the ossicula are anchylosed, or the membrana tym- 
pani and the membranes of the round and oval win- 
dows are thickened so as to lose their normal elasticity. 



THE EUSTACHIAN TUBE IN CHRONIC CATARRH. 163 

somewhat as the rigid and inelastic sclerotic assists in de- 
veloping the symptom of increased tension in glaucoma. 

Sensations in the tympanum dependent on the condition of the 
Eustachian tube and cavity of the ear. — The patient's voice 
may be heard with an unpleasant distinctness in the affected 
ear, and with an altered resonance, having a hollow, un- 
musical sound, for the same reason that the tuning-fork is 
heard longest in the affected ear. 

Crackling sounds are often heard in the ear, due to the 
violent interchange of air between the tympanum and the 
throat, owing to the faulty permeability of the tube. Dur- 
ing the act of deglutition air is frequently but not always 
interchanged between the tympanum and the throat, but in 
chronic catarrh this interchange may be almost constant, and 
sufficiently violent to cause movements in the membrana 
tympani. In other cases there may be no interchange at 
all in consequence of closure of the tube. The feeling 
of fulness in the ear may be due to hyperaemia of the 
tympanum, but it is more likely to be dependent on col- 
lapse of the membrana tympani. In some cases, where the 
ear has been too violently inflated and the air remains 
in the cavity, this sensation may be induced. The w r ay to 
remove this surplus of air is to stop the nose and swallow 
repeatedly. In both of these conditions (hyperemia and 
collapsed membrana) the ear may feel as though "stopped 
up" by something that ought to be removed. Sometimes 
the patient is annoyed by sounds proceeding apparently 
from the neighborhood of the Eustachian tube, which are 
produced possibly by spasmodic contraction of the tubal 
muscles, which force the walls of the tube tightly together. 

Where there are important throat symptoms the patient 
may complain of much pain in deglutition, or during 
this process an unpleasant rasping sensation may be ex- 
perienced, as though the walls of the pharynx were actually 
rough and rubbed together, producing a friction sound. In 
some cases there may be an aching pain in the throat, more 
likely to be found on the side of the most affected ear. In 
other cases there may be a burning pain in the inflamed spot, 
the parts feeling dry and hot. In pharyngitis sicca the pa- 
tient may have no pain, but the dryness will be very un- 
comfortable, the patient frequently desiring to moisten the 
throat. Especially will this be the case if much mouth 
breathing is practiced. The source of the pains described 
as being in the throat may be in the ear, and sometimes it 



164 DISEASES OF THE EAR. 

will be difficult to fix accurately the seat of the disease as evi- 
denced by the pain. [Within a few days I have seen a patient with 
pain in the ear, who had nothing about the ears or teeth to ac- 
count for it, and it was found that the condition of the throat 
gave rise to it.] The nostrils will sometimes be dry, but 
generally moist, with points of special irritation or inflammation. 
These may excite frequent attacks of sneezing. 

Objective Symptoms. — The meatus externus is usually preter- 
naturally dry, and more or less furfuraceous. In the earlier stages 
there may be impacted cerumen of greater consistency, and gen- 
erally of a darker color than normal. Afterwards, directly the op- 
posite condition is found ; the canal having little cerumen, and 



p.w. 




L.S. 



Fig. 46. 



Fie 40.— Collection in the tympanum: H.F., height of fluid; L. S., light spot Droken 
and diffused; CD., calcareous deposit in ant. sup. part; M.M., manubrium mal.; 
P.F., post, fold; A.F, ant. fold; S. F, short process ; A. IV, ant. wall; P. IV, post. wall. 

in some cases none at all. The sebaceous follicles likewise fail to 
secrete in normal amount. Near the membrana tympani the 
canal may be somewhat reddened and tender. This symptom is 
sometimes found in very chronic cases. Occasionally there 
may be some widening of the canal from atrophy of its subcu- 
taneous connective tissue, with absorption of fatty material. 

The membrana tympani shows the greatest possible variety of 
changes. In more recent cases, where only the mucous layer is 
involved, the light spot will not only not be dimmed, but will be 
of unnatural brightness, from the increased reflection from the 
somewhat opaque mucous layer. In more advanced cases the der- 
moid layer will become roughened, furfuraceous, and no longer 
capable of reflecting light at the umbo. Inflammatory exuda- 
tions into the fibrous or middle layer cause the membrane to 
become very opaque, giving it a dull, flat color, in strong con- 
trast to its normal pearly-gray, translucent appearance. In 
earlier stages, while there is considerable hyperaemia of the 
mucous layer^ the color may be of a reddish-brown tint. 



POSITION OF MEMBRANA IN CHRONIC CATARRH. 165 

If there are any collections in the tympanum, the mem- 
brana tympani opposite them will be darker than elsewhere, 
and if the color of the collection be decided, it may be ap- 
parent through the membrane (Fig. 46), but usually the 
membrane is too opaque to admit of this. By tilting the 
patient's head so as to change the level of the fluid, the dif- 
ferent appearance of the membrane will give evidence of 
this fact. On inflation, bubbles of air may fill the tym- 
panum, and show through the membrane somewhat con- 
spicuously. 

The position of the 7nembrana tympani is of great diagnostic 
importance. Sooner or later the Eustachian tube will have 
been obstructed sufficiently to result in collapsed drum 
membrane. It is brought about in this manner: there not 
being the usual supply of air from the throat on account 
of closure of the Eustachian tube, the remaining air in the 
tympanum is absorbed and an imperfect vacuum is formed 
in the tympanum. Under these circumstances the pressure 
of the outer air on the membrana forces it inward, in some 
instances to the nearly complete obliteration of the tym- 
panic cavity. 

As the incus, head of the stapes, and short process of the 
malleus are only slightly movable, the membrana is pushed 
down upon them so tightly that prominent points of these 
bones show conspicuously behind it. The short process of 
the malleus will be very prominent, the descending shank of 
the incus will sometimes be apparent behind the malleus 
handle, passing in the same direction, but not extending so 
far; the region of the head of the stapes maybe noticed, 
and the posterior ramus of the stapes itself sometimes shows 
beneath the membrane. If there is considerable anchylosis 
of the ossicula, the immovable malleus handle is often prom- 
inent and apparently divides the membrana into two un- 
equal portions. A more usual sign of sunken drum-head, 
however, is a pushing inward or retraction of the malleus 
handle, giving it a foreshortened appearance. 

Instead of the extending of the manubrium to near the 
centre of the membrana tympani, it will terminate at a 
point above the centre and usually somewhat posteriorly. 
This gives the manubrium a foreshortened appearance; it 
does not seem as long as the normal. In children this ap- 
pearance is greatly exaggerated, the manubrium being al- 
most in a horizontal position. 

The tendon of the tensor tympani emerges from the 



1 66 DISEASES OF THE EAR. 

anterior pyramid nearly opposite to its insertion near the 
neck of the malleus. There are, however, exceptions to this: 
sometimes the pyramid is situated more posteriorly than 
usual, and again it is located too far forward. In this event, 
if we admit that secondary retraction of the tendon of the 
tensor has occurred, and acted as a factor in the indrawing 
of the membrana tympani, then the malleus handle would 
take the direction of the point at which the tendon emerges 
from the anterior pyramid, and would be placed too vertical 
in the event of the pyramid being too far forward, and more 
horizontal if further backward. Politzer and Gruber have 
had much to say on this subject. My own impression is 
that the pressure of air on the outer surface of the mem- 
brana tympani is the cause of its collapes, for the most part. 
It is a matter, however, of the most common observation, that 
the inclination of the malleus handle does vary greatly, in 
some cases being nearly vertical, and in others as nearly 
horizontal. Another argument against the theory of retrac- 
tion of the tendon of the tensor is, that in marked cases of 
collapse of the membrane of long standing, the muscles of the 
tympanum become atrophic, their tendons undergoing fatty 
and other degenerations, naturally causing them to lose 
power. I know it is stated that the cause of the drawing in- 
ward of the manubrium is retraction of the tendon of the 
tensor, but if there is fatty degeneration very little retractile 
power could be expected from it. 

Indeed, the results of division of the tensor do not in the 
least sustain this idea. I have practiced the operation many 
times, and in the main have met with failure. Another ob- 
servation I have made regarding the malposition of the 
manubrium, which I also find mentioned byTroltsch, is the 
sabre-like shape of the whitish line in the membrana, placed 
over the malleus handle. This curve is convex behind and 
concave in front. For the upper half of its course it is rea- 
sonably clear that the manubrium is in apposition with the 
membrana tympani, but for the remainder of the distance it 
is evidently drawn away from the disconnected membrane, 
as though the latter could not follow its extreme excursion 
inward. The anterior fold is nearly always observable in a 
normal state- but in the collapsed membrane it becomes quite 
prominent, extending from the short process forward and 
downward in a curved direction, but sometimes nearly in a 
straight line, running downward and forward. 

Occasionally I have seen a rounded elevation at its com- 



APPEARANCES OF MEMBRANA IN CHRONIC CATARRH. 167 

mencement, in front of the short process, and much resem- 
bling the latter. 

The posterior fold is not as well observed in the normal 
membrane, but in its collapsed state it is generally seen ex- 
tending from a point behind and frequently above the 
short process, backward and upward, whence it passes 
downward in the direction of the posterior inferior periph- 
ery of the membrana tympani. It is not as sharply defined 
as the anterior fold, and sometimes has the appearance of 
merging with the wall of the meatus. If the malleus handle 
is drawn backward into a more horizontal position, the ten- 
dency is for the posterior part of the membrane to be less 
sunken and the anterior portion more so. The latter will 
be less sharply illuminated, and present a darker color, and 
the anterior fold will be much exaggerated. 

The light spot is perhaps as important in a diagnostic point 
of view as any other landmark of the membrana. It is a 
truism that nothing can obliterate the light spot but loss of 
polish of the dermoid or outer layer. No conceivable mal- 
position of the membrane is capable of removing the light 
reflex entirely. In the most variously sunken membrane 
some portion will still remain at right angles to the axis of 
the meatus, and will reflect light from this point to the ob- 
server's eye. Some have asserted that the position of the 
membrane may obliterate the light reflex, but I do not re- 
member ever to have seen such a case, and on theoretical 
grounds it seems impossible. 

The normal position of the reflex is, as has been already 
stated, in front of the malleus handle. It is of a somewhat 
triangular shape, with its apex near the extremity of the 
manubrium, whence it radiates towards the periphery, 
forming a somewhat obtuse angle with the anterior border 
of the manubrium. It may consist of one triangular spot, 
or several, or it may appear in the form of lines, its cor- 
rect position and size being the indication for its normal 
appearance. 

In the sunken condition it will form an acute angle with 
the manubrium, or this will be too obtuse, it will be too large 
or too small, may be seen in almost any portion of the mem- 
brana, or may consist of several light spots ; that is, wherever 
there is a depression or even an elevation there may be a 
light spot. I have seen them on the summit of the short 
process, on the rounded elevation at the commencement of 
11 



l68 DISEASES OF THE EAR. 

the anterior fold, besides on other parts of the folds, and on 
every conceivable portion of the membrane. 

In very great collapse a light reflex may often be seen at 
the periphery, more likely posteriorly, forming a long curved 
line, and running parallel to the periphery of the mem- 
brane. 

Calcific and other spots in the membrana tympani seem to 
depend on a previous inflammation of the membrane, al- 
though it is not always possible to demonstrate this fact. 
Many varieties have been described. Wilde speaks of num- 
erous small specks found on the membrane of a patient 
who had become deaf as a consequence of parturition. 
He makes observations on another class of cases in this 
wise; a membrane otherwise healthy, but with " a crescent- 
shaped opacity, about a line broad and three lines long, 
with a tolerably defined edge, and rather rough upon its 
surface, occupies the lower, and usually the back part, of 
the membrane." This spot is more insensible to the touch 
than the rest of the membrane, and has a well-defined edge. 

It gradually spreads over the whole of the membrane 
and produces permanent deafness. He has no cure for it. 
He regards it as consequent on some form of inflamma- 
tion of the tympanum (Wilde on the Ear: Phil., 1853, p. 274). 
According to the same author, on p. 276, atheromatous or 
calcareous deposits may be seen in the membranes of mid- 
dle-aged females. These are usually situated in the ante- 
rior portion, having a yellowish color, with sharply defined 
irregular edges, which feel gritty on being touched with a 
probe. 

They seem to be placed between the layers of the mem- 
brane, and resemble the atheromatous deposits in " the 
heart and arteries, and cornea." In each case there was great 
deafness; the sensibility of the part remained. Obviously, 
the spots of atheroma-like material, which Wilde describes 
as having a gritty feeling to the probe, must have invaded 
the outer layer of the membrana. Other spots resembling 
tendon, Politzer found to be placed between the fibres of 
the membrane, and were composed of fat corpuscles and 
granular matter. 

The whitish lymph-like looking spots gradually shad( 
off into the surrounding membrane, while the calcific spots 
are abrupt in outline. Many of these appearances are 
found in membranes where there has been suppurative 
otitis, or even a catarrhal inflammation of the tympanum. 



CALCIFIC CHANGES IN THE MEMBRANA TYMPANI. 169 

Beyond question all these changes are the result of a pre- 
vious state of hyperaemia or inflammation. 

Politzer found in some cases opaque spots, where the ex- 
citing cause seems to have been the small violence result- 
ing from brushing the membrana with a bit of cotton on a 
holder. Troltsch (in Dr. Roosa's translation) speaks of 
whitish points on the anterior superior part of the mem- 
brane, located in the mucous layer, but he is at a loss in ex- 
plaining their nature. 

It is a fact worthy of note, that these changes in the mem- 
brana are not as often observed in this country as in Europe. 
The reason of this is not apparent. Politzer, in his book 
on the Membrana Tympani (translated by Mathewson 
and Newton: Wood & Co., New York, 1869), speaks of the 
periphery of the membrane as being somewhat opaque nor- 
mally, in consequence of an excess of the circular fibres of 
the middle layer. The condition of opacity frequently 
seen, and resembling the arcus senilis corneae, he explains 
in this wise: there is thickening of the fibrous layer at this 
point, and the development of fat granules; in some cases 
the mucous layer also becomes thickened. It has been 
stated that as a rule the opaque spots do not necessarily 
stand in the relation of cause to the existing deafness. 
Troltsch is quoted by Politzer as saying, that when great 
deafness exists in conjunction with these changes, we may 
infer that similar appearances might be found in the oval 
and round windows. 

These appearances seem, according to Politzer, to result 
in this wise: the fibrous layer of the membrana has few or 
no blood-vessels, and these changes first appear as exuda- 
tions from the outer layers of the membrana, but more fre- 
quently from the mucous layer, which after a time undergo 
calcific degenerations. Ultimately a true bony formation 
may in a few cases result, the bone resembling that of the 
skull of a newly born infant. In chronic catarrh, Moos seems 
to have been the first to observe the formation of a calca- 
reous deposit in the membrana. It occurred in a woman 
seventy years of age. Besides the fatty matter and amor- 
phous material composed of carbonate of lime, dark-brown 
pigment molecules may be found interspersed between the 
fat globules. Politzer describes certain tendonous opacities 
which involve a large part of the membrane, the intervening 
normal portions appearing darker, and apparently but not 
really smaller. 



170 DISEASES OF THE EAR. 

In some instances Politzer found that the dermoid layer 
could be detached from the calcific formation, while in 
other cases it seemed to occupy all the layers of the mem- 
brana tympani. The mucous layer was more often incor- 
porated with the calcific mass than the outer layer. In 
many of the old cases of inflammation the tnembrana beco??ies 
atrophic and very thin, so as to bulge considerably on inflation, 
or to be drawn out excessively by Seigle's speculum, pre- 
senting the appearance of a thin cicatricial formation. 

In adhesions between the membrana ty??ipani and promontory 
the membrane will bulge on inflation, and may be seen to 
be fixed at the point of adhesion. A better plan is to use 
Seigle's tympanic speculum and exhaust the air, when the 
point of adhesion may be easily seen. 

Sometimes the malleus handle may be so adherent to the 
remaining ossicula or to the promontory, that no movement 
of the membrana is made on the most powerful rarefying or 
condensing of the air in the meatus by the pneumatic spec- 
ulum. This must not be considered diagnostic, however, 
for many times the manubrium refuses to move noticeably, 
even when there are no adhesions. In the latter instance, 
however, we may suspect anchylosis of the ossicula. 

The throat in chronic catarrhal otitis nearly always shows 
evidences of present or past inflammation. 

The tonsils, more especially in children, may be enlarged 
and full of scars, showing the results of former inflamma- 
tions. One tonsil is often more enlarged than its fellow, 
and probably will be found opposite the ear most affected. 
The uvula may be much swollen, but sometimes it is 
shrunken by atrophy, and may sometimes assume a spike- 
like shape, narrowing towards its termination. In many 
cases it will have a relaxed and somewhat cedematous ap- 
pearance. I have seen what appeared to be a large drop 
of serum confined in its lower extremity. In phonation the 
velum is often seen to rise up unsymmetrically, perhaps 
less so on the side of the affected ear, the consequence of 
muscular relaxation or paresis, or it may be much limited 
in its general movements. The lateral half arches also 
contract in a similar manner. This also interferes to some 
extent with deglutition. 

The voice is often affected, becoming unmusical. It 
may crack or break, and talking becomes very fatiguing, 
and singing is often impossible. The patient will talk in a 
high, shrill tone if there is considerable loss of hearing, 



THE NARES IN CHRONIC AURAL CATARRH. 171 

which is so marked a symptom that the aural surgeon can 
sometimes make a diagnosis of incurable deafness from 
this sign alone. 

These patients are very likely to need to use the pocket- 
handkerchief more than others; there may be a feeling of 
fulness in the frontal sinus, and headaches, and a dull feel- 
ing in the centre of the forehead due to the congestion of 
the mucous lining of the frontal sinus, or to obstruction 
to the flow of normal secretion from the sinus, through 
closure of the infundibulum, the result of catarrhal swell- 
ing. Again, the nostrils are unduly dry and scabby. On 
removing one of these scabs there may be a red or bleed- 
ing surface beneath, possibly granular. Sometimes the 
lining of the nostrils will be very pale and relaxed, giving 
rise to an excessive and thin discharge. 

The septum is frequently bent to the opposite side, mak- 
ing it difficult or impossible to introduce a catheter in 
the obstructed nostril. The turbinated bones are often 
swollen, hypertrophic, and in some instances polypoid ex- 
crescences may depend from them. Mucous and fibrous 
polypi are found attached to the turbinated bones, the 
septum or upper part of the space. Granulomata are 
occasionally found. 

The mucous lining of the nares resembles erectile tissue 
in many of its aspects. The slightest cause will often pro- 
duce a swelling of the lining of one or both nostrils, so 
that the patient is unable to breath through them. 

Often, while lying upon one side in bed, the upper nostril 
will be free and the lower one closed. This condition may 
be reversed on turning upon the opposite side. Again, if a 
patient becomes very much disturbed mentally, or is exces- 
sively fatigued, he may find, on retiring for the night, 
that his head is somewhat congested and the lining of the 
nares so swollen as to make nasal respiration difficult or 
impossible. This condition may disappear after the patient 
has become somewhat rested, and his condition of nervous 
irritation has passed off. I have no doubt but that the vaso- 
motory nervous system is at fault in such instances. The 
upper pharyngeal space will often give the patient trouble 
from a feeling of irritation or actual pain, accompanied by 
collections of thin mucous easily removed by efforts at ex- 
pectoration, strong nasal inspirations, etc., but dark or black 
or greenish masses of inspissated mucus may often be ob- 
served by the rhinoscopic mirror. These strongly adhere to 



172 



DISEASES OF THE EAR. 



the parts, and are only removed by syringing, and an act 
of screation on the part of the patient. Sometimes the vio- 
lence necessary to their removal will cause bleeding. I have 
noticed these masses frequently on the posterior nasal sep- 
tum. Occasionally they may be found on the vault of the 
pharynx, in the fossa of the Eustachian tube, or in that of 
Rosenmiiller. 

Fig. 47 will give a hint as to the normal appearances of 
these parts. 




Fig. 47- 
Outer wall of the left nasal cavity: 1, frontal bone; 2, nasal bone; 3. superior maxilla; 
4, body of the sphenoid: 5, superior; 6, middle, and 7, inferior turbinated bones; 8, 
orifice of the Eustachian tube. 

By rhinoscopic cxa7?iination of the Eustachian tube and its 
neighborhood (Fig. 48), the following conditions may be 
observed : increased redness in or about the mouth of the 
tube, or an unnatural paleness like that described in the nostrils. 

The mouth of the tube may be much swollen by hyper- 
emia. In other conditions cedema may produce a similar 
swelling, apparently obliterating the fossa of the tube, or so 
diminishing its size as to cause it to appear like a minute 
dimple ; or the elevation separating the fossa of the tube 
from that of Rosenmiiller may become greatly exaggerated, 
and sometimes surround the mouth of the tube like a col- 
lar. The posterior extremities of the middle and inferior 



RHINOSCOPIC IMAGE IN CHRONIC CATARRH. 173 



turbinated bones are found enlarged by swellings, rough- 
ened, and the posterior nares generally much distorted in 
appearance. Granulations like those found in the pharynx 
are often met with here. Polypi in the nares, when situ- 




FlG. 48. 

The rhinoscopic image in a normal pharynx: 1, nasal septum; 2, nasal passages; 3, su- 
perior meatus; 4, middle meatus; 5, superior turbinated bone; 6, middle turbinated 
bone; 7, inferior turbinated bone; 8, oiiiice of the Eustachian tube; 9, upper portion 
of the fossa of Rosenmuller; 11, glandular tissue at the vault of the pharynx; 12, 
posterior surface of the palate and uxula. (Cohen.) 

ated somewhat posteriorly, are visible by means of the 
rhinoscope. 

The mouth of the Eustachian tube is sometimes seen to 
move insufficiently or not at all during contraction of the 
tubal muscles, as in deglutition. This is better seen per- 
haps by Zaufal's nasal speculum (Fig. 49). 




000 



Fig. 49. — Zaufal's nasal speculum. Its three sizes are here indicated. Before intro- 
duction it should be anointed with vaseline. 

Cicatricial striae are often found in various parts of the 
upper pharynx, and sometimes the mouth of the Eustachian 
tube may be closed by bands of connective tissue passing 
across it, especially after the healing of a specific ulcer in 
the neighborhood. Quite as important as these changes 
are what W. Meyer of Copenhagen calls adenoid growths 
or vegetations, usually found in the vault or roof of the 
pharynx, and sometimes called pharyngeal tonsils. (Fig. 50). 
These are minute swellings or hypertrophies of the papillae 



174 



DISEASES OF THE EAR. 



of the mucous membrane. They are often so numerous as 
to fill the upper pharynx, making a rhinoscopic examina- 
tion impossible. By passing the finger behind the velum 
they may be felt, the sensation resembling that of a collec- 
tion of worms. Their dimensions are one or two lines in 
breadth, with a somewhat greater length. They bleed easily, 
may be broken off and removed by rough manipulation 
with the finger, and behave in many respects like an ordi- 
nary mucous polyp. 

There seems to be a large number of cases of adenoid 
vegetations on the continent of Europe, but here their cc- 




Fig. 50.— The normal appearances of the vault of the pharynx, showing- its glandular 
structure: 1-1, pterygoid process; 2, vomer; 3-3. posterior portion of the nasal fossae; 
4, Eustachian tube; 5, bursa pharyngea; 6, fossa of Rosenmliller; 7, irregular sur- 
face of the glandular tissue. (Luschka). 

currence is comparatively rare, according to the best ob- 
servers. 

Schwartze, in his " Pathological Anatomy of the Ear" 
(Dr. J. O. Green's translation: Houghton, Osgood & 
Co., Boston, 1878), states that on the tubal prominence 
and at the entrance of the pharyngeal orifice follicular 
ulcerations may be frequently observed, and " in caries of 
the temporal bone with destruction of the osseous tube 
ulcers from erosion are seen on the ostium pharyngeum, if 
the foetid pus flows into the pharynx in large quantities." 
He mentions that an extensive tuberculous ulceration in a 
man 33 years old reached to the middle line of the fornix, 
and the posterior pharyngeal wall, involving the cavity of 
Rosenmiiller, causing a deep excavation and destroying 
most of the tubal prominence. Syphilitic ulcerations on 



EUSTACHIAN TUBE IN CHRONIC CATARRH. 1 75 

the tubal prominence and at the entrance of the pharyngeal 
orifice, with ulceration on other parts of the vaso-pharynx, as 
the septum narium, choanae, fornix, and posterior wall of the 
uvula, can often be recognized by means of the rhinoscope. 
The Eustachian tube is rarely completely closed in chronic 
aural catarrh. During a number of years at the Manhattan 
Eye and Ear Hospital patients have been brought to me 
from another clinique, whose Eustachian tubes apparently 
could not be inflated. It was well known that I held the 
opinion that few tubes existed which I could not inflate 
with my faucial catheter. On actual trial I do not remem- 
ber a single case for a number of years that I have not 
been able to inflate. Ordinarily, when air refuses to pass 




<-0 

Fig. 51.— Toynbee's Diagnostic Tube. 

from the throat to the tympanum the cause maybe looked 
for in a collection of mucus, generally at the faucial ex- 
tremity, where so large a number of mucus-secreting 
glands are found, or the lining mucous membrane becomes 
swollen from hyperaemia, oedema, or infiltration into the 
sub-mucous connective tissue of the tube. The isthmus 
tubae is the first to suffer by diminution of its calibre. 
In other cases the tubal muscles, according to Weber- 
Liel, fail to act, and the walls of the tube fall pas- 
sively together, so that no interchange of air between the 
throat and tympanum is possible during deglutition or 
whenever contraction of the muscles ought to take place. 
In this condition Politzer's or Valvalva's inflation fails to 
open the tube, and only the catheter, possibly assisted bya 
bougie, succeeds in forcing air into the tympanum. It is in 
this condition that treatment to increase the power of the 
tubal muscles is indicated. 

Objective Symptoms of Obstruction or Closure of the Eustachian 
Tube. — On inspecting the membrana during the act of deglu- 



176 DISEASES OF THE EAR. 

tition, if there is no movement visible it points towards 
the fact of non-interchange of air between the throat and 
tympanum. As this may occur frequently in a normal 
state, it has only a moderate significance, and we cannot 
assert positively by this test that the tube is obstructed or 
narrowed. By means of the diagnostic tube of Toynbee 
(Fig. 51) we listen for the sounds resulting from the act of 
deglutition. We hear a certain distant and indistinct rum- 
bling sound, which is caused by the contraction of the 
muscles concerned in deglutition, accompanied by a moist 
friction sound consequent on the rubbing together of the 
opposite surfaces of the mucous lining of the throat. 

If air enters or leaves the tympanum freely, indicating a 
normal state of the tube, a tolerably distinct "click" or 
"crackle," caused by movement of the membrane, may be 
heard. If the tube is absolutely closed the first two sounds 
will be heard, but not the last. If the tube is pervious and 
the tympanum contains fluid, then a moist, mucous, or 
gurgling sound will be heard. 

In making these tests the utmost quiet should prevail, 
and the diagnostic tube must be very carefully inserted into 
both the observer's and the patient's ear, and it should not 
be allowed to touch any intervening object, as a loud fric- 
tion sound would result, greatly distracting the attention 
f "om the auscultation sounds. On inflating the ear by Val- 
valva's method, the only sound heard will be that produced 
Dy the entrance of air into the tympanum. This is accom- 
panied by a rather sudden sound like a thud, and a rustling 
or crackling of the membrane, provided the latter moves. 
All of the sounds produced in the tympanum seem to be 
made almost within the observer's ear, so near do they ap- 
pear to be. This is the best method of studying the sounds 
produced by inflation, for they are not modified by the 
blowing sound of the catheter or the deglutition sounds of 
Politzer's method. The moist crackling of fluid in the tym- 
panum is quite easy to recognize. I do not believe that aus- 
cultation can differentiate between a tolerably dry tympan- 
um and a normally moist one; the fluid must be in the tym- 
panum in considerable quantities in order to be detected by 
this test. Where the tube is much narrowed, instead of 
obtaining a sudden and immediate thud-like sound, there 
will be a somewhat prolonged, faint, and possibly squeaking 
sound. If the tube is stopped with inflammatory products 
and the inflation removes them, then the sound will be 



AUSCULTATION OF THE EAR. 1 77 

slower in making its appearance, and will be more pro- 
nounced. If the patient makes a very violent effort at in- 
flation by Valsalva's method, the muscular contraction 
concerned in the act may be faintly heard in the distance 
as an indistinct rumbling sound, but this is not a frequent 
occurrence. 

In Politzers operation the sounds of deglutition are the 
most distinct of any heard, and have been already de- 
scribed. The inflation is more prompt, the thud or crackle 
is of a sharper character and much more pronounced in 
quality than in any of the other methods of inflation. It is 
not as prolonged as that of either of the other methods, 
but the tube being widely opened a large volume of air 
fills the tympanum instantaneously, producing the infla- 
tion sound very promptly. 

Naturally these remarks do not apply to the various 
modifications of Politzer's operation, where the patient 
blows air out of his mouth or utters the words Hick, hack, 
etc. A moist sound here, is distinguished in the same man- 
ner as in the other methods described. 

In one case, on practising inflation I fancied I heard the 
rupture of an adhesion in the tympanum. It is safe to say 
that the imagination is sometimes called into play while 
studying these sounds. 

On inflating with the catheter there is first the prolonged 
blowing sound incident to forcing air through a tube. As 
the proper insertion of the catheter includes the idea 
that it must fit into the tube so inexactly that most of 
the air forced into it escapes into the throat rather than 
the tympanum, there must be an addition to the blowing 
sound made by this escape of air into the pharynx. 
Whether air enters the tympanum or not, the blowing 
sound is heard well enough; but if it passes freely through 
the Eustachian tube into the tympanum the blowing sound 
is then heard as though it were produced in the observer's 
ear. This symptom is sometimes very startling. I do not 
remember to have made much out of the sounds produced 
by the movement of the membrana while using the cathe- 
ter, though the moist tympanal sounds are easily heard. 
The auscultatory sounds while using the faucial catheter 
for inflating the tympanum are similar to those obtained 
by the use of the ordinary catheter. After making several 
efforts at inflation without eliciting any sounds, it will be 
well to direct the patient to swallow several times, while 



178 DISEASES OF THE EAR. 

the nose is closed so as to empty a possibly overfilled 
tympanum, so that subsequently a considerable quantity 
of air may be forced in, which may elicit decided ausculta- 
tion sounds. 

A plan I have used very much to test the Eustachian 
tube, is easy to accomplish and quite striking in its results. 
While inflating, inspect the membrane carefully, and if 
even a small amount of air has entered, it may be deter- 
mined by the appearance of the membrane — it has changed 
its position. 

It may not be possible to see any movement; but if the 
position of the light reflex be carefully noted, together 
with the peculiar form of illumination of the membrana 
tympani, the slightest possible change of position of the 
membrane may be detected by the change in the size or 
position of the light reflex. Indeed, with the movement of 
the membrane the reflex may be obliterated, and perhaps 
one or more new ones caused to appear in other parts of it. 

The change in the illumination of the membrane is also 
a conspicuous symptom. When the membrana was light 
it may become darker, and vice versa. New features of 
expression, so to speak, may be brought out. Other methods 
still, of determining a pervious tube are more valuable than 
that by auscultation. 

The effect of inflation on the hearing is one of the most 
valuable of tests, and is the easiest to apply of any. 

If the hearing is improved by inflation, the tube is per- 
vious; if the hearing is lowered this is still true; if tinnitus 
results, or if an existing tinnitus is relieved, the tube is per- 
vious; if there is no change in the hearing, the tube may be 
pervious. If the patient feels something in the ear not be- 
fore noticed, the tympanum has been inflated; if no sensa- 
tion is produced the tympanum may have been inflated. 
Relief of pain in the ear, or the production of a pain from 
an attempt at inflation, proves a pervious state of the tube. 

Another test of inflation of the tympanum, on which great 
stress was formerly laid, I believe to be of little moment — 
that is, the reddening of the membrane, or any part of it, as a 
consequence of the inflation, and therefore an evidence of it. 
In the Transactions of the American Otological Society for 187 1, 
p. 49, I have recorded the results of 287 inflations of the 
tympanum. The cases were mostly of chronic aural ca- 
tarrh, but a few were normal. Of the 287 inflations in 31 
cases, 224 did not redden the membrane, 53 did, and 10 



PATHOLOGICAL CONSIDERATIONS. 179 

were doubtful. Thirty-two inflations were done by steam, 
in a very thorough manner, without reddening the membrane 
in the least. Forty-seven inflations were done in patients of 
normal hearing, with congestion of the membrane in 21 
instances, no effect 25, and uncertain 1. Inflation of the 
old cases, with sclerosis and atrophic bloodvessels, as 
might have been expected, did not often result in redden- 
ing of the membrane, while the more recent ones much 
more frequently did. Occasionally I found a case where 
the slightest inflation produced a considerable reddening 
of the membrana. These observations seemed to point to 
the fact that inflation is capable of doing considerable vio- 
lence to the tympanum, and it has been known to cause an acute 
otitis. Blowing the nose may rupture the membrane. 

Pathological Considerations. — In chronic catarrh, the mu- 
cous lining of the tympanum, in the earlier stages, may be 
more or less swollen and reddened from increased vascu- 
larity, or preternaturally pale, secreting more than a nor- 
mal amount of mucus or sero-mucus, the mucous glands 
being hypertrophic. The submucosa may be thickened by 
cell-proliferation, consequent on the inflammation. Occa- 
sionally the secretion may be sufficient to cause the mem- 
brane to bulge and to require evacuation. At a later stage 
the opposite condition may be found, when great dryness 
of the tympanum results, in which there is atrophy of the 
mucous glands, and a condition resembling that of pharyn- 
gitis sicca. In earlier stages " villous prolongations and 
slight elevations are seen on the surface of the membrane" 
(mucous lining of the tympanum); "the thickening may 
be confined to certain spots, the mucosa of the drum mem- 
brane, the maleo-incal articulation, labyrinthine fenestrae, 
or it may be equally distributed over all portions of the 
membrane, and may even completely obliterate the whole 
of the tympanic cavity.". . . "With the thickening of the 
mucous membrane the membrana tympani appears thick- 
ened, leathery, and but slightly yielding to the touch." . . . 
"Marked thickening from a new growth of connective 
tissue on the fenestrae of the labyrinth, and around the ar- 
ticulation of the malleus and incus, are specially injurious 
to the conduction of sound. The niche of the fenestra 
rotunda may be completely closed, and the ossicles may 
be wholly imbedded in the hypertrophied mucous mem- 
brane, so that careful preparation is necessary to render 
them visible." 



180 DISEASES OF THE EAR. 

Bands of connective tissue, the result of inflammatory 
proliferation, are frequently found in the tympanum. The 
membrana may be bound to the promontory by adhesions 
resembling the synechias of iritis. It may be brought 
about in this manner, according to Schwartze: When the 
membrana from any cause is pressed inward so as to touch 
the inner wall, the epithelial surfaces are destroyed by 
pressure, and the mucous membrane becomes changed into 
a vascular granulation tissue, which is subject to the usual 
cicatricial contraction." . . . " Still more common than this 
direct union are the so-called pseudo-membranous growths. 
They occur simultaneously in various forms in the same 
ear, and may be so numerous that the whole cavity ap- 
pears to be filled with an irregular network. They are so 
common as to be found in about every fifth ear (Wendt); 
when recent they appear of a red or grayish-red color, soft 
and succulent from serous infiltration; when old, whitish- 
gray, or white and firm." . . . "They may unite the ossicula 
with each other, or with the wall of the tympanum; the drum 
membrane with the tympanic wall, the stapes, or the long 
process of the incus; the tendon of the tensor tympani muscle 
with the roof of the cavity or the ossicula; very frequently 
an arm of the stapes with the walls of the fenestras ovalis. 
The fenestra rotunda and the ostium tympanicum tubas 
may also be completely or partially covered by them, thus 
causing complete or partial closure of these openings." 
The tendon of the tensor tympani may in such cases 
also become involved. Sometimes the tympanum may be 
divided into several cavities by these bands. Where these 
adhesions are tense and rigid the sound conduction is inter- 
fered with, especially with synechias on the stapes, owing to 
its very limited normal vibration. 

Many of these membranous bridges are the remains of 
the mucous tissue which fills the tympanum of the foetus 
and new-born child; they are the result of incomplete retro- 
gression of this tissue. 

" The pathological connecting bands are produced". . " by 
the contact and union of portions of the mucous membrane 
when in a state of swelling and proliferation." If adhesions 
between surfaces are extensive, there will be wide bands or 
considerable membranous formations, but if only a narrow 
adhesion takes place the synechias will be narrow like 
strings or threads. Especially will this be the case if after 
an adhesion has formed it is stretched by movement of the 



PATHOLOGY OF CHRONIC AURAL CATARRH. l8l 

drum membrane outward during inflation. This is analo- 
gous to the synechiae of iritis. 

It is not possible to distinguish between the adhesions 
resulting from the remains of the foetal mucous cushion 
and those dependent on pathological processes. It is quite 
probable that these cicatricial bands and membranes act as 
exciting causes of recurring attacks of otitis, as iritis with 
adhesions provoke recurring attacks of iritis. These mem- 
branes and bands undergo the same retrogressive changes 
that other similar tissues do, as atrophy, fatty degenera- 
tions, sclerosis and cicatricial contraction, calcification, and 
ossification. 

When the membrana has been sunken for a long time it 
may rest against the head of the stirrup, the incus being 
pushed aside in consequence of a subluxation dependent 
on a distended and relaxed capsule. Rigidity and immo- 
bility, with or without anchylosis in the annular ligament 
of the stapes and in the malleo-incus articulation, is very 
common. 

" The capability of vibration in the ossicula is diminished 
by thickening or rigidity of the mucous membrane which 
covers these bones (sclerosis, calcification, or ossification of 
the periosteal connective tissue, with cellular and serous in- 
filtration of the sub-epithelial layer), by synechiae, and by 
the imbedding of the bones in hypertrophied connective 
tissue (membranous anchylosis)." 

" If the whole annular ligament, or even the periosteal layer 
of the mucosa which covers it, is changed into a mass of 
lime, absolute immobility of the stapes results. Similar 
results may be obtained by osseous changes in this region, 
the latter being more likely to occur in those more advanced 
in years, although not necessarily so. If the stapes has 
been immovable for a long time the crura become atro- 
phied so that they break at a slight touch. 

"The malleus and incus may become ossified with the 
upper wall of the tympanum." . . " Exostoses on the os- 
sicula" are common on the incus, but less so on the malleus 
and least so on the stapes. 

" Enchondromata apparently are developed quite often 
on the sharply projecting processus brevis, such as is seen 
with a retracted drum-membrane." In synechiae between the 
promontory and membrana resulting in arresting the func- 
tional activity of the tympanal muscles, the latter may un- 
dergo fatty or fibrous degeneration, or become atrophic." 



1 82 DISEASES OF THE EAR. 

. . . "Shortening of the tendon of the tensor tympani may 
result" . . . "from connective-tissue adhesions between the 
tendon and its sheath;" . . . "from retraction of the mu- 
cous covering of the tendon the result of thickening of the 
general tympanic mucous membrane," as described by Pol- 
itzer, or " from membranous or thread-like synechias con- 
necting the sheath of the tendon with the roof of the tym- 
panum or with other parts of the cavity." ..." Hinton 
found fibromata on the tendon of the tensor tympani." 
" In the Eustachian tube in the earlier stages there is con- 
gestion, swelling, and increased secretion of its mucous lin- 
ing." 

The mucous secretion, as in the throat, may become in- 
spissated and block up the whole of the tube, forming a 
jelly-like mass, sometimes projecting from the faucial ex- 
tremity of the tube. Similar masses have been found at 
the same time in the tympanum. 

" There is also in chronic cases a marked projection and 
wrinkling of the mucous membrane perpendicularly to the 
axis of the canal (at the pharyngeal orifice), with hyper- 
trophy of the glandular layer and thickening of the sub- 
mucous connective tissue." Other changes occurring in 
the pharyngeal extremity of the tube are detailed under 
the head of Rhinoscopic Appearances. 

Granular changes in the lining of the tube sometimes 
occur. " Small spots of ossification in the tubal cartilage 
have been described by Moos;" calcification of the same 
also sometimes occurs. 

" Contraction or stenosis of the Eustachian tube even to 
complete closure takes place from swelling of the mucous 
membrane or thickening of the submucous connective tis- 
sue in catarrh, from hyperplasia" ..." at the pharyngeal 
orifice." 

" Hypertrophic thickening of the soft palate, by which the 
anterior lip of the tube may be pressed against the poste- 
rior lip," so as to close the tube, sometimes occurs. The 
pharyngeal tonsils may be so swollen from hyperplasia as to 
partly cover the mouth of the tube and compress it so as to 
render it a mere slit (generally the pharyngeal tonsil is 
above and behind the orifice of the tube, and does not en- 
croach on it). " New growths in the naso-pharynx, such as 
naso-pharyngeal polypi, large cysts, cicatricial bands," . . . 
"great swelling of the lower nasal cartilages, or great hy- 



PATHOLOGY OF CHRONIC AURAL CATARRH. I 83 

pertrophy of the palatine tonsils/' result in closure of the 
tube. 

" Real strictures, in the sense in which urethral strictures 
are formed, by thickening and atrophic shortening of the 
tissues, appear not to occur in the Eustachian tube." 

"An osseous stricture of the tube" . . . "below the os- 
tium tympanicum was seen and figured by Toynbee in the 
Med. Times, Feb., 1850. A bristle could scarcely be passed 
through it." 

In atrophy of the mucous membrane of the naso-pharynx 
the ostium pharyngeum appears unusually wide open and 
deep. The tubal prominence then projects very much, and 
from the thinning of its mucous covering appears almost 
bare." 

"Acquired enlargement of the canal" occurs in con- 
nection with sclerosis of the mucous membrane of the 
tympanum, when it may become three or four times its 
normal calibre." . . " The tube may also gap throughout 
its entire length, according to Rudinger, in the Monat- 
schrift fiir Ohrenheilkunde, 1868, No. 9, in consequence of 
atrophy of the musculus dilator tubae. Fatty degeneration 
and atrophy of the tubal palatine muscles are the frequent 
results of chronic retro-nasal and tubal catarrh." ... "A 
muscular hypertrophy of the musculus tensor veli palati vel 
dilator tubae has been described by Moos as the result of 
chronic tubal catarrh." 

In the above pathological observations the quotations 
refer to Herman Schwartze, M.D., on the Pathological 
Anatomy of the Ear, translated by J. Orne Greene, M.D. 

The prognosis of chronic aural catarrh depends on many 
factors. 

These are as follows: If the patient has a good constitu- 
tion, without any strong catarrhal tendency, and the dis- 
ease has produced no great change in the tympanic lining, 
he will make a good recovery, with hearing normal or suffi- 
cient for the ordinary avocations of life. The swelling of 
the lining of the tympanum and Eustachian tube altogether 
disappears, the exudations which may have taken place be- 
come wholly absorbed, the Eustachian tube returns to its 
normal functional activity, and the membrana assumes a 
perfectly correct position. [The following case from the New 
England Medical Monthly, Jan., 1884, will illustrate the prog- 
nosis of this variety of the disease :] 

Miss X., age 24, came to my office about five years since, on 
12 



1 84 DISEASES OF THE EAR. 

account of a collection of cerumen in each auditory canal. I 
at once removed it by means of the syringe. The hearing be- 
came nearly restored, and, after inflation by Politzer's method, 
was perfect. I concluded that the pressure of the cerumen on 
the drum head had caused some sinking of this membrane. 
At the time there was no catarrh of the fauces, Eustachian 
tubes, or of the tympanic cavities. A slight tinnitus aurium 
was also relieved by the removal of the cerumen. I stated to 
the patient that she should be on her guard on account of the 
probability of the occurrence at some future period of an aural 
catarrh. No other treatment at this time was recommended. 

About one year from this date another collection of cerumen 
made its appearance, which was removed as before, with like 
result. In eight or ten months another collection of cerumen 
appeared, which was again removed, but the hearing did not 
fully return in the right ear. She now had some signs of 
catarrh of the upper pharyngeal space, the parts were red- 
dened, slightly granular, and a collection of mucus was noticed 
behind the velum pendulum. I may remark here that she 
belongs to a family in which deafness is prevalent, I conclude 
from chronic naso-pharyngeal catarrh, although there are 
no signs of struma. She lives in Brooklyn, the air of which is 
somewhat conducive to catarrhal affections. 

On this occasion I commenced treatment of her catarrh, and 
practised inflation of the ears by Politzer's method. The hear- 
ing of the right ear soon came up to the normal, and after two 
or three weeks of treatment remained perfect. I sprayed the 
upper pharnyx with a forty gr. solution of arg. nit., every two 
or three days, using my hard rubber spray instrument for the 
purpose, being careful not to over stimulate the parts. 

She remained cured for about one year, when the collection 
of cerumen reappeared, with the symptoms of chronic aural 
catarrh ; on this occasion I found more difficulty in relieving 
the symptoms, especially the tinnitus aurium, but after about 
four weeks of treatment complete relief was obtained. Since 
this there has been several relapses of the hearing, with tin- 
nitus and the accompanying catarrh in each instance, but a 
cure has been effected. Within the last four months there has 
been the most serious relapse of all, both ears being affected, 
and the tinnitus being quite annoying. 

At the present time, November, 1883, the hearing of the left, 
the originally better ear, is quite restored, the hearing distance 
for an ordinary watch being about eight feet. There is no tin- 
nitus. In the right ear the hearing is between seven and eight 



PATHOLOGY OF CHRONIC AURAL CATARRH. 1 85 

feet, she just perceiving that the left ear has better hearing than 
the right. There is still a very little tinnitus in the right ear occa- 
sionally. Treatment is continued at intervals of one or two weeks. 
She is directed to remain away as long as she has no important 
symptoms, but to return whenever there is any considerable 
trouble. The catarrhal symptoms have disappeared, with the 
exception of a little hyperemia of the right Eustachian tube. 

I conclude that this case is the analogue of many which are 
allowed to go on without treatment until irreparable damage to 
the hearing results. I will not undertake to say that all cases 
of aural catarrh are thus amenable to treatment, for it is well 
known that there are many cases where an apparently rheu- 
matic tendency exists, and the fibrous layer of the lining of the 
drum cavity becomes inflamed, which obstinately resists treat- 
ment. Such cases are alluded to in the books as progressive 
hardness of hearing. One point in the treatment of this case 
I would refer to. I did not over inflate the drum cavities — 
only inflating whenever the hearing was below the normal. If 
inflation is done too frequently, the drum membranes are pressed 
strongly outward, placed upon the stretch, and after a time all 
elasticity of the tissue becomes destroyed, and we may have a 
membrane which flaps to and fro whenever there is the slightest 
interchange of air between the throat and the tympanum. 

I spoke in the commencement of the probable occurrence of 
aural catarrh, because the cerumen had become impacted. In 
cases of impacted cerumen which I reported in the Trans, of 
the American Otolog. Soc, 1872, I raised the question that the 
presence of impacted cerumen was probably a result of some 
form of irritation about the ear, liable to result in mischief. I 
believe this view has been confirmed by others. 

Another case under treatment at the present time is quite the 
analogue of this one, although the cerumen has never been im- 
pacted — only a moderate collection adhering to the walls of the 
canals — and what is somewhat infrequent, it is very dry, so as 
to fall out of the ear of its own accord. In this case there was 
at first (about three years since) no deafness, tinnitus, nor aural 
catarrh, but after about one year all these symptoms have made 
their appearance. At present the patient is convalescent, ex- 
cept that the cerumen is inclined to collect in spite of treat- 
ment. The first case herewith reported, at the present time 
shows little tendency to the formation of cerumen in consider- 
able quantities, acting in accordance with a well known law. 

Again, if the patient be inclined to catarrh, — that is, if he 
fails to resist the irritating influences of our climate, — he may 
be cured of a first, second, or third attack, and so on, but 



1 86 DISEASES OF THE EAR. 

at each relapse the hearing may fail to be perfectly restored, 
and after a time a high degree of deafness may result. 
From this it may be inferred that the hearing which fails 
to come up to the normal standard a few weeks after a re- 
lapse has occurred, is likely never to do so, For the most 
part this is true. 

In this class of cases it is easy to infer that the important 
indication is to prevent the relapses, on which the unfavor- 
able prognosis depends. 

In the cases already referred to, an obstructed Eustachian 
tube as one of the factors on which the progsis turns, is pre- 
supposed. 

In a few subjects, notably the tuberculous, who ma} 7 rare- 
ly have a period even of complete recovery from catarrhal 
symptoms, the tube may never be normally pervious, in 
spite of our treatment; this symptom being the important 
one in determining the prognosis. They will often hear very 
well while the tympanum is inflated, but the tube fails to 
keep up a normal supply of air in the tympanum. Again, 
the Eustachian tube may have become pervious, but changes 
in the tympanum may have taken place, rendering recovery 
of the hearing impossible. A reference to the topic of 
Pathology in this article will render this point clear. An- 
other class of cases will have a pervious tube and a collapsed 
membrane, with considerable deafness, dependent on the 
collapse. On inflation the hearing will be much improved, 
and if there has been tinnitus the latter may be relieved; but 
on the first effort at deglutition the tube opens, and the air 
in the tympanum rushes into the throat. The membrana, 
which had been kept in position only by the excess of intra- 
tympanic air-pressure, flies back to its old position, and the 
deafness and tinnitus return. These cases are not bene- 
fitted by treatment, except possibly by operations hereafter 
to be described. The membraneous bands in the tympanum 
are not removed by treatment, although occasionally they 
may be ruptured by inflation, much as synechiae in the iris 
are broken by atropine, or they may even be divided by a 
tenotome. On the whole, however, comparatively little is 
accomplished. There is still another class of cases where 
the disease has gone on to atrophy of the mucous lining of 
the tympanum together with its glands, resulting perhaps 
from a previous condition of connective-tissue proliferation 
of its mucosa, where the membrana is much thinned, easily 
bulges on inflation, is too translucent, and the reflex from 



PROGNOSIS OF CHRONIC AURAL CATARRH. 1 87 

the promontory shows a bloodless condition of its lining, 
the Eustachian tube being not only pervious, but perhaps 
of increased calibre from atrophic changes, not only in its 
cartilaginous but its osseous portion. Naturally under 
such conditions no improvement could take place by infla- 
tion, and nothing remains to be done by way of effecting 
absorption of inflammatory products, for they have disap- 
peared in the slowly retrogressive changes until a condition 
of sclerosis is the result. Naturally this class must occur 
in persons advanced in years, for nothing but a consider- 
able lapse of time could eventuate in such ultimate changes. 
As a matter of fact, no amount of treatment can benefit these 
cases. 

It has not been quite fully admitted in treatises on the ear, 
but it is nevertheless a fact, that most if not all the cases of 
profound deafness from this disease result, in part at least, 
from labyrinthine complications. Under the head of Diag- 
nosis will be found the mode of determining what class of 
cases have these complications. As a rule, and I hardly re- 
member an exception, the deafness in these cases which de- 
pends on the labyrinth trouble is incurable under all circum- 
stances. Another rule in prognosis is invaluable; in a case 
of chronic catarrh, where no further diminution of hyper- 
emia may be hoped for from treatment, and where there are 
plainly nointra-tympanal adhesions, the amount of hearing 
to be expected from treatment is that which may be gained 
by inflation. Once in a long time I have increased the hear- 
ing beyond the highest point obtained at first. It is diffi- 
cult to explain this: it may require several visits before the 
exact amount of air is injected into the ear which will ensure 
the highest possible amount of hearing, and the failure to 
carefully settle this point may have been my source of error. 

Tinnitus aurium in more recent cases may often be re- 
lieved, but if the tinnitus has continued several years or 
perhaps six months, it is rarely cured. Many patients are 
solicitous as to whether their hearing will be still further 
impaired. The answer to that appears in what has already 
been stated : if inflammatory processes are still in operation 
a greater amount of deafness may be expected, but in oth- 
ers just described, where the fire of inflammation is as it 
were burned out, — that is, where sclerosis exists, — no 
further impairment of the hearing may be expected. The 
same rule sometimes seems to apply to tinnitus aurium. 

In certain advanced cases it seems to disappear without 



1 88 DISEASES OF THE EAR. 

treatment, but as numerous labyrinthine conditions, undis- 
covered during life, act as causes of tinnitus, it will appear 
that an accurate statement of prognosis in a given case is 
impossible. 

When the patient's voice is considerably altered so as to 
produce the loud, harsh, and discordant tones previously 
described, the prognosis of any considerable improvement 
to the hearing cannot be made. The same is true if the 
patient has a peculiarly observant manner, so to speak, 
eying one at every turn, showing that he depends on his eyes 
rather than his ears to determine what is said. The younger 
the patient the more favorable is the prognosis. 

The average aural surgeon is able to say to an old or el- 
derly subject who has been hard of hearing for several 
years, that there is no hope of relief. If there are periods 
of comparatively good hearing, or if the patient hears bet- 
ter in fine weather, the case is more hopeful. If the patient 
hears much better in a noise, it is of ill omen for a favor- 
able prognosis. If there are occasional deep-seated aching 
pains in the ears, or if they are sensitive to cold air, there 
is likely to be progressiveness of the hardness of hearing. 
Troltsch, in his Treatise on Diseases of the Ear, translated 
by Roosa, quotes Politzer to the effect that if a patient has 
a persistent tinnitus the prognosis is bad, even though de- 
cided improvement to the hearing may suddenly occur. 
The latter will probably not be permanent. 

When the first sign of trouble is tinnitus, continuing some 
time without perceptible loss of hearing, the prognosis is 
unfavorable. Large calcareous spots on the membrana 
with great deafness, according to Troltsch, " are, as a rule, 
very unfavorable for treatment." "These degenerations 
are generally connected with morbid processes on the fe- 
nestra rotunda and ovalis." 

Treatment of Chronic Aural Catarrh. — General considera- 
tions. — Inasmuch as this disease is a consequence of inflam- 
mation of a mucous membrane, which usually commences 
in the throat and nares, and travels up the Eustachian 
tubes to the middle ears, causing the mischief already de- 
tailed under the head of Pathology, our endeavors should 
be directed to the subduing of this inflammation and reme- 
dying as far as possible its consequences. The throat and 
nares should be restored as nearly as possible to a normal 
state and maintained in that condition. The nares espe- 
cially should be looked after, as a free passage of air 



TREATMENT OF CHRONIC AURAL CATARRH. 1 89 

through them is essential to the well-being of the Eusta- 
chian tubes and drum cavities. This has been discussed 
under the heading of Acute Catarrh. The Eustachian tube 
must be rendered pervious, and any atony or paresis of its 
muscles or a collapsed condition of its walls should receive 
appropriate treatment. The membrana needs to be forced 
outward by inflation or other means; any hyperemia of the 
drum cavity must be disposed of; bands of adhesion in the 
tympanum should be broken up or divided if possible; 
rigid or sclerosed conditions of the membrana require at- 
tention, and when the Eustachian tube is impervious to air, 
the membrane maybe punctured or incised to maintain the 
proper amount of air in the tympanum. Although this is 
a chronic disease, the relapses of inflammation that are 
frequently met with are more of the nature of an acute af- 
fection, and on the management of these will largely de- 
pend our success in treatment. It should be clearly under- 
stood that when a catarrh has reached a certain stage of 
development very little is gained by treatment. In earlier 
stages, if the patient has some pain, especially if it be of a 
throbbing character, it will be proper to use one or two 
leeches on the posterior surface of the tragus, every two or 
three days, until all pain or feeling of fulness has disap- 
peared from the ear. Care needs to be taken, however. 
Do not mistake the pain and feeling of fulness due to a 
collapsed membrane for the pain of hyperemia. I pur- 
posely avoid speaking of inflation at this juncture, for one 
would infer, from reading some of the books on the ear 
written since Politzer devised his method of inflation, that 
this was almost the principal treatment of chronic catarrhal 
otitis. I well remember the mistake a pupil of mine once 
made. He had heard me say much about inflating the ear 
and rendering an obstructed tube pervious, so he tried the 
treatment on a patient with chronic aural catarrh, but the 
hearing failed to improve as he had expected; he then 
brought the patient for advice. I found the tube moder- 
ately pervious and inflation did not improve the hearing. 

It was obvious that the cause of the deafness was in the 
congested state of the tympanum and not in the obstructed 
tube. I applied one leech to the posterior face of the tragus 
every three or four days; each time the hearing improved, 
and at last it was so perfect that the patient found no diffi- 
culty in practising an avocation quite trying to the hearing- 
— that of a stenographic law reporter. Other means are 



190 DISEASES OF THE EAR. 

serviceable in diminishing the hyperaemia of the tympanum. 
Warmth, moist or dry, preferably the latter, is very effec- 
tive. The most elegant method of applying dry heat is by 
means of a rubber bag containing warm water and laid on 
the ear. The details of this method are found under the 
heading of acute inflammation of the middle ear. I have 
often noticed in old cases that occasional aching pains 
would appear from time to time in the ear, with reddening 
of the inner end of the meatus, and perhaps slight redden- 
ing of the membrana. Such cases have been relieved by 
painting tr. of iodine on the inner extremity of the canal, 
and sometimes lightly on the membrane itself. Care must 
be taken to make the application lightly, as it may be 
painful when too much is used. Besides the warm appli- 
cations to the ear, the latter should be kept warm, if need be, 
by a bit of cotton in the meatus, or an ear muff may be 
worn. If the ear is becoming congested from the cold, 
there will be a painful sensation, or at least a feeling of in- 
sufficient protection from the cold when the temperature is 
too much lowered. The prevention and cure of hyperaemia 
of the tympanum are at all times very important steps in 
the treatment of this disease. 

Where in the earlier stages of inflammation there still 
remains hyperaemia, mucous or sero-mucous collections 
are likely to be found in the tympanum. These should 
always be removed by paracentesis or otherwise. In- 
flation of the tympanum, if the collection is not of too 
great consistency, may be sufficient to remove it through 
the Eustachian tube. A physician under my care had 
serous collections in his drum cavities. I removed them re- 
peatedly by paracentesis, but he, at length evidently be- 
coming wearied with the punctures, caused its removal in 
the following manner: he inflated his tympanum by Valsal- 
va's method, turned his head forward and somewhat to the 
opposite side, when the excessive air-pressure in the tym- 
panum, aided by the elastic membrana, forced the collec- 
tion into the throat. Large doses of iodide of potass, will 
sometimes put an end to these intra-tympanal collections, 
or full doses of quinine will sometimes accomplish this re- 
sult. A strong solution (20 to 40 grs.) of arg. nit. applied to 
the mouth of the Eustachian tube, or even painted on the 
membrane, will often accomplish the same result. When 
the collection depends on a membrane collapsed from in- 
sufficient air-pressure on the walls of the vessels of the 



PUNCTURE OF MEMBRANE IN CHRONIC CATARRH. I91 

tympanum, the obvious procedure is to inflate and restore 
the normal air-pressure upon the tympanal vessels. Where 
puncture becomes necessary, the rule already laid down 
in the chapter on acute inflammation of the tympanum 
may be followed. It is not a very painful operation, and 
in some cases causes no pain whatever. There will some- 
times be no bulging of the membrane, so the puncture may 
be made almost at any point not high enough to touch the 
chorda tympani, which passes across the tympanum above 
the short process of the malleus, nor in the vicinity of the 
extremity of the long process of the incus, for by so doing 
we might disarticulate it from the stapes, or wound the 
oval window. If it is done rather high up and posteriorly, 
by which means a deeper portion of the tympanum will be 
reached, permitting more thorough penetration of the instru- 
ment, and consequently a wider incision in the membrane 
will result; the paracentesis needle should be held so lightly 
in the fingers that by the sense of touch we may determine 
just when the membrane is punctured. After the opening 
is made the tympanum is to be inflated while the head is 
turned towards the affected ear. If the fluid is removed 
with difficulty in this manner, apply a rubber tube or Sei- 
gle's speculum to the meatus, and by exhausting the air 
(and if need be repeat the inflation at the same time) the 
tympanum may be thoroughly emptied. Do not, however, 
exhaust too strongly, or blood may flow and the ear become 
hypersemic. 

This process may require to be repeated many times. The 
following case from Dr. Burnett, in his Treatise on the Ear 
(Henry C. Lea, Phila., 1877, p. 428), illustrates this point: 
A gentleman 80 years of age had a brownish transparent 
fluid in the tympanum, visible only through a thin de- 
pressed cicatrix. Eustachian tube impervious. Hearing 
for the watch was ^ . Twenty or thirty drops of fluid 
were removed by incision; hearing arose to nearly the nor- 
mal degree. In one week the tympanum filled again: 
another puncture was made, with results similar to the first; 
in another week a slight return of a " muffled feeling" was 
relieved by a third puncture, with the escape of a small 
amount of fluid, when the hearing became normal and re- 
mained so. 

Another case from the same author: July 1, 1874; a gen- 
tleman, aged 55, for the last year has noticed a gradual 
diminution of hearing in the left side. Treatment by in- 



192 DISEASES OF THE EAR. 

ffation was employed by other physicians, which did some 
temporary good. Hearing distance, watch, ■£$. Inflated 
the ear several times a week for over a month, which tem- 
porarily improved the hearing. On September 12th the 
patient stated that he felt something like a drop of fluid 
moving in the ear whenever he turned his head about; when 
he lay down he heard better. As this seemed to indicate 
the presence of fluid in the tympanum, puncture was re- 
sorted to, resulting in the evacuation of about twenty drops 
of a brownish, transparent, serous fluid, with streaks of 
opaque mucus. Hearing distance increased from one 
inch to five feet. Complete relief continued until March, 
1875, when, after a cold, he had a feeling of fulness in the 
ear, but there was little sensation of movable fluid. A 
paracentesis again gave relief. By the 23d the ear filled 
again, and was punctured with similar results. On April 
15th he had the muffled sensation in the ear, and again the 
membrane was punctured with relief. On May 8th and on 
June 8th the same procedure was followed by similar re- 
sults, and the patient had no further trouble until Septem- 
ber 8th, when the symptoms returned, and a puncture was 
again made; also one on October 26th, November 24th, and 
January 3d, 1876, February 19th and March 28th. On Feb- 
ruary 19th air-bubbles were visible in the tympanum 
through the membrane, which could be seen to move 
under Valsalva's inflation. Complete relief resulted from 
the last operation. It is astonishing how small a collection 
in the tympanum will suffice to lower the hearing. Some 
time since I had a case of chronic otitis, in which the pa- 
tient grew suddenly deaf without apparent cause. I ob- 
served that the light reflexes on both the drum membranes 
were extraordinarily bright. The membranes were both 
much sunken, and at first it did not seem possible that fluid 
could be lodged in the tympanic cavities. The excessively 
bright reflexes on the membranes, however, led me to 
suspect the presence of fluid. I punctured, and by means 
of inflation removed not more than two drops of fluid, with 
the result of at once rendering the hearing nearly normal. 
The collection returned several times, and after each punc- 
ture results similar to the first were obtained. The patient 
noticed subsequently, besides the sudden deafness, a ful- 
ness as though the ear were stopped up or had something 
in it. There was no sign of the fluid by inspection, the 



PUNCTURE OF MEMBRANE IN CHRONIC CATARRH. I93 

membranes being too opaque for the fluid to be seen 
through them. 

I am of the opinion that in view of the fact that it is 
often impossible to diagnosticate fluid in the tympanum by 
inspection, that an exploratory puncture is justifiable, it 
doing no harm, causing little or no pain, and only leaving 
a little soreness behind which is of little consequence. 
Some years since I read a paper before the New York Med- 
ical Journal and Library Association on operations on the 
membrana tympani, in which between two and three hun- 
dred punctures of the membrane were recorded. Only a 
few resulted in inflammation and pain, and in none was 
the hearing lowered. 

Counter-irritation behind the ear may do something 
towards diminishing an hyperaemic tympanum. This is 
at least an unfashionable measure at the present time, and 
there is danger that its merits will not be properly recog- 
nized. Cantharidal collodion may be used for this pur- 
pose, being applied with a brush over the mastoid region 
every four hours until vesication results. Care needs to be 
taken not to touch the sulcus behind the auricle, for a very 
disagreeable ulceration may result. Dress the blister in 
the usual manner. It may be kept open by occasional ap- 
plications of the cantharidal liniment, or the collodion may 
be reapplied when the first application no longer causes 
sufficient irritation. 

A plan I like very much is to paint the part with tr. 
of iodine every day, until considerable irritation is pro- 
duced. This is less painful, and does not cause the rather 
offensive moistening of the parts characteristic of the 
blister. It may be well to keep up irritation for weeks, and 
sometimes for a month or two. 

When the throat comes under consideration much may 
be said about the effect of counter-irritation applied to 
that part as favorably affecting the tympanum, possibly by 
reflex action. 

Any means whatever which lessens the flow of blood to 
the head is likely to diminish hyperemia of the tympanum. 
When the cerebral vessels are full, and the tympanic injec- 
tion seems to be in any way connected with it, it will be 
proper to administer bromide of potass, or ergot, with a 
mustard plaster, perhaps, at the nape of the neck. A warm 
foot-bath will often give relief. 

Under the head of Acute Catarrhal Inflammation of the 



194 DISEASES OF THE EAR. 

Ear, it was recorded that change of climate often relie\ed 
a hypersemic condition of the tympani in a few hours or 
days. It is well to remember that if the patient is fatigued 
or harassed, or has been insufficiently nourished, the tym- 
pani will become congested if the patient has been affected 
with chronic aural catarrh. Then the obvious treatment is 
rest and food, and sometimes stimulation will have the 
effect of overcoming any local congestions. 

Means for the correction of the faulty position of the drum 
membrane may be used at any time, even when relapses oc- 
cur. For the most part this will consist in blowing air 
through the Eustachian tube, to produce a normal supply 
in the tympanum, and by excess of air-pressure to force the 
membrane outward. On the whole, Politzer's mode of infla- 
tion is the best. By it there is no forcing of the tube. During 
the act of deglutition the latter is opened, and air naturally 
passes into the tympanum in consequence of the inflation. 
The amount of inflation necessary is to be determined 
as follows: as long as the hearing improves, continue to 
inflate. If after a time the hearing is lowered, then an ex- 
cess of air has entered the tympanum, and it will be proper 
to desist. If pain results, inflation has been overdone. If 
tinnitus is caused by the inflation, or if the patient is ren- 
dered giddy or faint, there has been too much air forced 
into the tympanum. The inflation ordinarily may be re- 
peated as often as the good effect of the first has passed 
away. I would not, however, give the patient a bag for 
self-inflation. In many instances this practice has resulted 
in destroying the elasticity of the membrane, so that when 
it is forced outward it remains in an unnaturally flat or 
bulged condition, or it has become so limp as to flap to 
and fro with every change in the intra-tympanal air- 
pressure. 

Enough has already been said of the mischievous effects 
of excessive inflation. By my own experiments previously 
recorded, it has been seen that hyperemia and even inflam- 
mation of the tympanum may result from injudicious in- 
flation. 

Where the tube walls are collapsed, the Eustachian ca- 
theter will become necessary to inflate the tympanum. It 
has been argued by many, and notably by Dr. Roosa, of 
New York, that the contact of the end of the Eustachian 
catheter with the faucial extremity of the tube, by its irri- 
tation, produces a remedial stimulation on the lining of the 



TREATMENT OF THE EUSTACHIAN TUBE. 195 

tube, and unloads blood-vessels by the increased discharge 
caused by the contact of the catheter. It certainly is true 
that the tube becomes more pervious to Politzer's method 
of inflation after the catheter has been used. 

On the other hand, it has been argued that whatever 
causes irritation to the mucous membrane aggravates the 
catarrhal condition. This seems certainly to be true in 
the treatment of the lachrymal sac and nasal duct. A few 
years since, bougies were introduced into the latter and al- 
lowed to remain from a few hours to a day or two. The 
practice was found to aggravate the previous catarrhal con- 
dition, and was abandoned. Now, many only leave the 
probe in from a minute or two to not more than ten min- 
utes. This is my own practice. I certainly feel that the 
Eustachian tube should not be unduly irritated. 

Another objection to the use of the catheter is its pain- 
fulness. Even if not actually painful, it is extremely disa- 
greeable. Introducing it in one's own nostril will suffi- 
ciently settle this point. . 

Again, it is frequently impossible to introduce it in 
consequence of malformation of the nostril, or changes in 
its calibre incident to the catarrhal condition. It is true 
that Dr. Noyes' double-curved catheter (see Index) may be 
introduced into the tube through the opposite nostril, if 
that happens to be permeable. 

Again, it is often desirable to inflate only one ear instead 
of both, which the catheter does much better than can be 
done by other methods. I am aware that Dr. Knapp of 
New York and Gruber of Vienna have added a long ta- 
pering tip to the Politzer nose-piece, so that the ear on 
the same side as the nostril into which the tip is intro- 
duced is more likely to be inflated. My faucial catheter 
.'trill also inflate one ear only at a time, and is therefore de- 
sirable for the same reason that the Eustachian catheter is. 
Dr. C. J. Blake, of Boston, in the Progress of Otology in 
the Report of the First International Otological Congress, 
New York, 1877, quotes Josef Gruber in the M. /. O., No. 
10, 1875, as suggesting a new method of practising Polit- 
zer's inflation: While the air is forced into the nostrils, the 
patient is directed to pronounce the words hack, heck, hick, 
hock, huck, by which means the base of the tongue rises 
up, presses against the soft palate, and pushes it upward 
and backward against the posterior pharyngeal wall, and 
shuts off the upper from the lower pharyngeal space. If 



196 DISEASES OF THE EAR. 

the patient's head is inclined to one side during inflation, in 
this manner, the air passes into the ear which is uppermost. 
Dr. E. E. Holt, of Portland, Me., suggests that by filling 
the cheeks with air during inflation of the tympanum, that 
the act of deglutition may be dispensed with. 

Dr. J. O. Tansley, of New York, directs the patient to 
purse up the lips and blow air out of the mouth strongly, 
as though a lamp-flame were to be blown out. I have lat- 
terly practised Dr. Tansley's blowing method, and find it 
effective. Repeating the letter K successively is also a good 
manoeuvre. 

The other methods are more complicated, and the pa- 
tient gives trouble in understanding what is wanted of him. 
I am sure that Politzer's method, with a hospital patient of 
the usual intelligence, is sometimes quite troublesome to 
apply. 

With children, none of these details are necessary. 
Their tubes are of large calibre and easily forced. The 
more frightened they become the more likely is the soft 
palate to fly back upon the posterior pharyngeal wall, and 
shut off the upper from the lower cavity. Valsalva's method 
is objectionable, as it often imperfectly inflates the tym- 
panum, and frequently does not inflate it at all. Conges- 
tion of the cerebral vessels sometimes results from the 
straining effort in inflating by this method. It is claimed 
by many that the pressure of the column of air in the tym- 
panum acts as a stimulant to the mucous lining, acts cura- 
tively on the inflamed membrane, and excites absorption of 
inflammatory material. I am by no means certain that the 
effect is more than mechanical, dislodging obstructions 
from the tube, dilating it, and forcing the membrana into 
a better position. Where there is reason to believe that ad- 
hesions between the membrana and the ossicles, or inner 
wall of the tympanum, exist, it will be proper to inflate 
with considerable violence, using at the same time Siegle's 
otoscope to assist in the outward movement of the mem- 
brane. I believe I have ruptured S3mechige by these means. 
Ordinarily I would not use traction by Siegle's instrument, 
nor any other method of suction, to aid in the outw r ard 
movement of the membrane, as practised by Dr. Howard 
Pinckney, of New York, and others. Dr. P. has, however, 
reported some good results from this practice. In my ex- 
perience it has congested the drum cavity, increased the 
tinnitus, caused giddiness and faintness, and has shown a 



INFLATION OF THE TYMPANUM. 197 

tendency to lower the hearing. It seems to cause too much 
violence. When speaking of the management of the Eus- 
tachian tube it was stated that other methods were more to 
be depended upon for restoring a normal supply of air to 
the tympanum than these. Where the Eustachian tube is 
impervious, or of such small calibre as to admit of insuffi- 
cient ventilation of the tympanum, it will be proper to punc- 
ture the membrane for the purpose of increasing the sup- 
ply of air. 

A large incision is not necessary, as in any event the 
aperture closes in a day or at most a few days. This being 
temporary in its effects, repetition is called for. 

I have a chronic catarrhal patient who comes to the hospital 
occasionally to have his tympanic membrane punctured. The 
symptoms of insufficient air-supply in the tympanum are an- 
noying enough to cause him to apply for the relief which he 
has so often experienced. In his case it causes very little pain 
or subsequent soreness, and he always expresses himself as 
relieved by the operation. I do not always take the trouble 
to use a speculum, but depend on the sense of feeling in 
making the puncture. 

1 The main cause of failure in this is the wonderful 
power of the membrana to repair itself, so that it mat- 
ters not how large a portion of the membrane has 
been removed, nor by what means, repair is likely to 
take place sufficient to close the tympanic cavity, and 
defeat the object for which the operation was per- 
formed. F. E. Weber first recommended the division of 
the tensor tympani muscle near its insertion on the ma- 
nubrium, together with any adhesive bands which might 
prevent the membrana from assuming its normal position. 
His theory was to this effect: The tendon of the tensor, 
during a long-continued collapse of the membrane, had un- 
dergone a secondary retraction, so that the membrane could 
no longer assume a normal position, even though the Eus- 
tachian tube was pervious and sufficient air-supply could be 
obtained for the tympanic cavity. Besides the pressure upon 
the contents of the tympanum, perpetuated by this enforced 
collapse of the membrane, a constant exciting cause of ca- 
tarrh of the tympanum existed. Weber-Liel divided the 
tendon by entering the tympanum through the membrane, 
in front of the malleus handle, and catching it at that point. 
His instrument consisted of a handle of sufficient size and 
length to be conveniently grasped. To this was attached 



198 



DISEASES OF THE EAR. 



the tenotome, which consisted of a hooked knife attached 
to a narrow shaft, the end of which was fixed to the ex- 
tremity of the handle at a somewhat obtuse angle. At the 
latter point there was a cog attached to a movable button 
or slide in the handle, enabling the thumb, when the in- 




Fig. 51. 

1, Gruber's tenotome and adjustible handle; 2, Gruber's tenotome; 3, J. O. Greene's 
tenotome; 4, 5, two views of Hartman's tenotome. 

strument was grasped, to push this slide or button down- 
ward, causing the knife to make a revolution of about one 
fourth the circle. 

After passing the knife into the tympanum, and hooking 
it on to the tendon of the tensor, the latter is divided by 
causing the revolution of the knife as before described. In 



OPERATION FOR DIVISION OF TENSOR TYMPANI. I99 

removing the instrument from the tympanum the hook 
should be revolved in an opposite direction to that which 
accomplished the division of the tendon. 

I much prefer Gruber's instrument. The knife is quite 
different from Weber's, as seen by the accompanying cut 
(Fig. 51). The blade of the knife is one cm. long, slight- 
ly curved at the end. It is fastened by a screw in a han- 
dle, which admits of its being adjusted for either ear. Fol- 
lowing the suggestions of Voltolini and J. Orne Greene, I 
have always done the operation posteriorly to the malleus 
handle, instead of in front, as Gruber suggests, and have 
used Greene's modification of the Gruber knife oftener 
than otherwise. The latter, represented by Fig. 3 in the 
cut, is a blunt, spatula-shaped knife, curved flatwise, as is 
Gruber's. Being of this shape, it is less liable to wound 
any important parts in the tympanum; moreover, it admits 
of being somewhat wider near its extremity, and conse- 
quently may be made to cut better. Greene penetrates the 
membrana with a pointed instrument preparatory to using 
the tenotome, but I have found that this tenotome may be 
pushed through the membrane without undue violence, 
thus simplifying the operation. My mode of operating is 
to enter the membrane near the extremity of the manu- 
brium, extend the incision upward until the tendon is 
reached; divide this by an up and down motion of the knife. 
The numbers 4 and 5 in the figure refer to Hartman's teno- 
tome. It has a double curve — one upward on its cutting 
edge, and the other forward on its flat surface, so as to 
prevent injury to the stapes and to the chorda tympani 
(Burnett). I have purposely written briefly on this subject, 
because I believe it to be comparatively unimportant. In 
Germany some years since the operation was frequently re- 
sorted to by many of the more eminent aural surgeons, and 
comparatively good results were reported. In this country 
the operation has not been done extensively, as the indif- 
ferent results of the operations done by the few who have 
attempted it have deterred others from doing it, Bertolet, 
of Philadelphia, and myself being among those who were 
comparatively unsuccessful in this operation. I occasion- 
ally succeeded in relieving tinnitus aurium by the operation 
(about one in twelve or fifteen), and usually not improving 
the hearing more than temporarily, which indeed a simple 
paracentesis may do. 

As far as I am at present informed, the operation is in- 
13 



200 DISEASES OF THE EAR. 

frequently done in this country, and much less frequently 
in Europe than formerly. It is sometimes justifiable where 
everything else has failed to relieve tinnitus aurium, for 
this does sometimes succeed. 

The operation of puncturing or opening the mem- 
brana to add air-supply to the tympanum, where the 
calibre of the Eustachian tube is insufficient for the 
purpose, has been performed in a great variety of modes; 
and as it is often desirable to maintain an opening for 
a considerable time, or permanently, a variety of expe- 




Fco 52.— Warner's Post Nasal Syringe. 

dients have been resorted to for the purpose of accomplish- 
ing that end, such as making an opening by the galvano- 
cautery, the trephine, dissecting out a piece of membrane, 
burning holes in the membrana with sulphuric acid, the in- 
sertion of an eyelet, etc., etc. It is safe to say that some of 
these procedures have been successful. 

On the Management of the Eustachian Tube. — The first point 
is to free the tube of inflammatory products. Very often 
the faucial end of the tube will be filled with mucus, either 
inspissated or of a tenacious consistency. It is well to in- 
ject a little tepid salt-and-water, of the strength of a drachm 
to the pint, behind the velum, by any properly constructed 



MANAGEMENT OF THE EUSTACHIAN TUBE. 201 

syringe having a bend in the tip, so as easily to pass behind 
the velum. It will be seen that I have a fear of passing 
fluids into the middle ear by these injections, and in all the 
cleansing processes of the upper pharyngeal space I act 
with reference to that fear. 

It will be well to first throw up only a few drachms of 
the warm salt-and- water; it may be done in this manner: 
draw up the syringe piston to the whole distance, even 
though there is only a drachm or two of water to be used, 
then forcibly send the piston home, by which means a some- 
what coarse spray will be produced. If a soft rubber bag 
is used, like Warner's instrument (Fig. 52), the same idea 
may be carried out. Any spray-producer maybe sufficient 
for our purpose, or a small quantity of water may be thrown 
into the nostrils by an atropine dropper, the head being 
thrown somewhat backward during the operation. 

If the tube then inflates easily, enough has been done to 
free the pharyngeal extremity from mucus. Frequently, 
however, firm adherent masses of mucus may be seen by 
the rhinoscope to cling to the fossa of the tube, completely 
closing it; then more effective means may be necessary for 
its removal. The syringe may be entirely filled with the 
salt water, and thrown in with some force. It will be well 
to pause now and then, and request the patient to make an 
effort to remove these masses in the natural manner. 
Sometimes I make the remedial application at once, and 
the suddenly increased secretion of the part may throw off 
the mass, but in any event it assists the patient's efforts to 
remove it. If the treatment progresses favorably, this 
forcible removal of the masses of mucus will soon become 
unnecessary. In all these efforts to cleanse the tubal orifice 
the patient should not cough, nor sneeze, nor swallow, nor 
violently catch his breath, nor for a little time even blow 
his nose, for fear of forcing fluid into the middle ear. If 
on attempting inflation by Politzer's method, or its modifi- 
cations, difficulty is experienced in rendering the tube per- 
vious, the catarrhal application may at once be made, when, 
from the increased discharge resulting, the tube may at 
once become pervious to the renewed effort at inflation. I 
believe the explanation of this to be the same as that recently 
given for a similar action of the catheter. The same end 
may be accomplished by the use of the faucial or the 
Eustachian catheter, introduced previous to the Politzeriza- 
tion. I lay great stress upon using Politzer's method, be- 



202 DISEASES OF THE EAR. 

lieving, as I have previously stated, that it is the most 
thorough and satisfactory of all methods of inflation. 

If there seems to be few catarrhal symptoms, and the 
patient does not have recurring attacks of lowered hearing, 
it may not be necessary to make any application to the 
mouth of the tube: In increasing the calibre of the tube 
by catarrhal applications to its mouth, is it necessary to go 
further and treat the mucous lining of the nares and 
pharynx, wherever diseased; if not absolutely necessary, 
it certainly is desirable; and most American authorities, as 
Roosa, Buck, Burnett, and others, express the belief that 
in treating the Eustachian tube the pharyngeal and nas^.i 
mucous membrane requires attention. Von Troltsch is 
decidedly of the same opinion. I shall, however, first con- 
sider the topical applications suitable for the mouth of the 
tube, and the best method of applying them. 

The remedy I have the greatest confidence in, and which 
I have used, almost since I first commenced the practice 
of otology, is the nitrate of silver. The selection of the 
proper strength to use requires great skill on the part of 
the surgeon. If used in small quantities, as a drop or two 
or less, a very strong solution may be used. If used in 
larger quantities, as one or two drachms thrown into the 
pharynx, a weak solution should be employed — from one to 
ten grains to the ounce. When used in the form of spray, 
the remedy being diluted, so to speak, with air, a strong 
solution may be used, and if the spray is a fine one, a still 
stronger solution is proper. If the application has been 
excessive, the catarrhal symptoms may be aggravated for 
months afterwards; at least I have seen patients who in- 
sisted that this was so. Nitrate of silver seems poisonous 
to some throats. There should not be an unpleasant irrita- 
tion of the part, lasting more than an hour or two. I fear 
we are often at fault in making our applications unneces- 
sarily strong. Some time since I had a medical man under 
my charge with chronic aural catarrh. As he was skilled 
in auscultation, his hearing could be appreciated with most 
acute intelligence. After a few weeks of treatment the 
hearing would come up to the normal. He had several re- 
lapses, but at present his condition is perfect. He made 
this observation about the treatment: while actually under 
treatment his condition was not as satisfactory as some 
days or a week or two after the discontinuance of the treat- 
ment. He was conscious that the good effects continued 



TREATMENT OF THE EUSTACHIAN TUBE. 



203 



some time after its discontinuance. I inferred from this 
that I had been too heroic in my applications. 

The methods of applying nitrate of silver to the Eustach- 
ian tube which I have the most experience with are as 
follows: A drachm or two of a weak solution may be thrown 
behind the velum, the patient being directed to expectorate 
as soon as the application is made. Send it up as directed 
for the salt-water injection. Again, a stronger solution, 
perhaps one of twenty grains, may be used by the same 
method; that is, draw into the syringe six to ten drops, 
the valve being extended as though it were to be filled, 
then send it home sharply. The spray instrument is de- 
servedly popular. I use the hard rubber instrument which 
is sold in the shops in New York as Pomeroy's (Fig. 53). It 



^B 




Fig. 53. — Pomeroy's Hard Rubber Spray Instrument. 



is not my practice to use with this a weaker than a ten- 
grain solution, and often I use as high as a sixty or eighty 
grain solution. The spray may be directed to the mouths 
of the tubes or to the whole pharyngeal space. My faucial 
catheter (see Index), according to my experience, affords 
one of the most exquisite methods of applying arg. nit. to 
the mouth of the tube. It may be used as follows: With a 
dropping tube, deposit a part of one drop, or two or three 
drops, upon any convenient surface, such as a piece of 
writing-paper or a palette; then compress the air-bag, 
having the thumb on the aperture, until the fingers on the 
opposite side of the bag touch the thumb, the compressed 
bag being between them; then apply the tip of the instru- 



204 DISEASES OF THE EAR. 

ment at its perforated extremity accurately on the drop of 
solution; then allow the air-bag to fill sufficiently to draw 
the fluid within the catheter, the thumb being still on the 
aperture in the bag. Allow the bag now to fill with air, 
mostly by relaxing the close application of the thumb to 
the aperture; then introduce behind the velum, to a point 
as near the mouth of Eustachian tube as possible; then 
compress the bag strongly. When a small quantity of the 
fluid is used (and it is perfectly easy to deposit on the 
palette one tenth of a drop) the solution may be made 
very strong. I have thus used a saturated solution. I use 
this instrument in private practice, for the above purpose, 
much more frequently than any other. Some years since, 
when the instrument was new, and I needed to test its 
capacities fully, I found on rhinoscopic examination that it 
was quite easy to throw the solution into the fossa of the 
Eustachian tube in nearly every instance. The fluid is not 
intended to pass into the tympanum, nor even more than a 
little way up the tube. In a few instances I have injected 
the tympanum while using it, but without doing harm. 
Some years since, Dr. Robert F. Weir, of New York, used 
my instrument for making an application to the Eustachian 
tube, and a suppurative otitis resulted. I have never heard 
of another instance of the kind. If the bag is compressed 
strongly, the fluid passes out of the catheter in the form of 
a coarse spray. [Since writing the preceding I have met with 
one case where nitrate of silver was injected by myself into the 
tympanum, but without doing more harm than causing some 
pain.] 

The Eustachian catheter is an admirable instrument for 
making applications to the pharyngeal entrance of the 
tube. Some years since I appropriated a method of using 
this instrument, which Dr. Agnew, of New York, suggested to 
me, and which he had been using for a long time. The 
catheter for this method has a moderate curvature, so as 
readily to pass into almost any nostril ; it was attached to 
a light rubber tube, which again fitted the tip of an ordi- 
nary Politzer bag, having a perforation. The fluid was 
drawn up into the catheter by means similar to those used 
in charging the faucial catheter, although I believe Dr. 
Agnew was in the habit of inserting the catheter into a 
bottle of nitrate of silver, finding that he could draw up in 
that manner a sufficiently small quantity ; he then intro- 
duced it as near to the faucial extremity of the tube as 



TREATMENT OF THE EUSTACHIAN TUBE. 



205 



possible, and compressed the bag with some force. By 
this means the tube was treated, and the tympanum in- 
jected with air at the same time. This method admits of 
rapid work, although the catheterization of the tube is 
likely to be done somewhat imperfectly. Another method, 
which is more exact, is to introduce the catheter, having 
a maximum bend, carefully into the mouth of the tube, 
hold it in position by the hand, or a catheter holder (my 
own — see Index — is a convenient one), or if it is perfectly 
inserted it will remain in position without aid ; then, the 
patient's head being thrown somewhat backward, the ni- 




Fig. 54.— Hackley's Instrument for Spraying the mouth of the Eustachian Tube. 



trate of silver may be passed into the opening in the cathe- 
ter by a medicine-dropper. The air-bag, provided with 
a tip accurately fitting into the catheter, which for ob- 
vious reasons may be attached to the bag by a short rub- 
ber tube, is then ready for use. Several compressions of 
the bag may be necessary to sufficiently blow the medicament 
out of the catheter. Two or three extra drops may be 
allowed, as that amount is likely to adhere to the walls of the 
catheter. 



206 DISEASES OF THE EAR. 

Many are in the habit of causing the patient to swallow 
during compression of the bag, but the objection to this is 
the greater tendency of the fluid to pass into the middle 
ear. Fig. 54 represents Dr. Hackley's method of spraying 
the mouth of the Eustachian tube by means of the Eus- 
tachian catheter. A Politzer bag, with tube and attach- 
ment for a catheter, is penetrated near its extremity by a 
hypodermic syringe charged with a fluid. The rubber tube 
by its tip is pushed into the catheter, either before or after 
it is applied to the mouth of the tube. Then, by pushing 
down the piston of the hypodermic syringe, a proper amount 
of fluid is injected into the catheter. By compressing the 
Politzer bag, the fluid is forced into the Eustachian tube. 
Another method of making applications to the Eustachian 
tube as well as any part in its vicinity, is by the use of 
Zaufal's speculum (see Index). Select the largest one 
which will pass into the nostril, and make the application 
by means of a cotton holder, armed with a small, tightly 
rolled bit of cotton immersed in a strong solution of arg. 
nit. If any granulations are found, a saturated solution 
would be of a proper strength. Dr. Prout, of Brooklyn, 
who introduced the instrument into this country, recom- 
mends anointing the speculum with vaseline previous to its 
introduction. 

I have little to say about probangs, brushes, or the cotton 
on a holder, as means of making applications behind the 
velum, although many men of the highest authority use 
and recommend them. It is true that an application thus 
made has a certain quality of thoroughness, as the rubbing 
of the part incident to the application removes secretions 
which often prevent the remedy from reaching the surface 
of the membrane. In making applications to the posterior 
surface of the pharynx, velum, etc., it is preferable to any 
other method. When passed behind the velum, consider- 
able violence is likely to result in the endeavor to reach the 
proper point. 

If this is not positively injurious, it is at least very an- 
noying and often painful to the patient. Even if he is di- 
rected to phonate, breathe through the nose, etc., to cause 
the velum to hang loosely down, there certainly is likely to 
be spasmodic contraction upon the probang, making it dif- 
ficult to remove, and thus causing pain and irritation. It 
certainly is proper to use these methods, although I do not 
personally like them. In using Zaufal's speculum, a most 



TREATMENT OF THE EUSTACHIAN TUBE. 207 

elegant plan, when a strong effect is desired, is to fuse a 
bead of arg. nit. on a probe and make the application to the 
mouth of the tube. For an account of the indications for 
the use of this speculum (see Page 173). Many other applica- 
tions may be made to the Eustachian tube. Tincture of 
iodine may be cautiously applied by means of the catheter, 
syringe, or spray instrument. If undiluted, only a small 
quantity should be used — a drop or two by the catheter or 
two to four with the syringe. In using the spray, a mo- 
mentary application will suffice. This may also be diluted 
with alcohol and used as described for the weak solutions 
of arg. nit. It is often painful. In the older and dryer 
catarrhal conditions it is more applicable, being much more 
stimulating than astringent. Carbolic acid is a mild, not 
very effective remedy, but its action is agreeable to the pa- 
tient, and I have used it in many mild cases with satisfac- 
tory results. It should always be used rather weak — from 
two to five grains to the ounce of water. Dobell's solution is 
a pleasant preparation of carbolic acid. IJ. Acid carbol., gr. 
i.; sod. biborat., sod. bicarb., aa. gr. ij. ; glycerinse, 3 i.; aquae, 
I i. M. The spray instrument is an admirable means of using 
these solutions, or the posterior nasal syringe; with the 
latter, one to three drachms may be thrown behind the uvula 
and removed by expectoration. It should not be allowed 
to touch the borders of the nostrils, as considerable sore- 
ness may result. It may also be used, poured into the nos- 
trils with a pretty large atropine dropper, or by a little 
earthenware instrument called a sick feeder, having a nozzle, 
which adapts itself to the nostril. In using this, the patient 
throws the head slightly backward, and the solution should 
pass into the pharynx, to be removed by expectoration. I 
sometimes add to this wash, with good effect, forty to sixty 
grains of tannin to the pint. Ferric alum latterly has become 
somewhat popular in this connection, used in from one to 
four grain solutions in water. It has a somewhat unpleasant 
metallic astringent taste, and is likely to soil instruments 
and clothing. Its predominant quality is astringency. I 
believe it to be somewhat more effective than common 
alum. The latter may also be used in the same manner 
and same strength. Chloride of zinc in from one to four 
grain solutions, used in the same manner as the last, may 
be recommended. This remedy is more stimulating than 
those just mentioned, somewhat resembling the nitrate of 
silver in its action. Occasionally it is rather painful. Sul- 



208 DISEASES OF THE EAR. 

phate of zinc has a well-established reputation in this affec- 
tion, and may be used in a two to four grain solution. I 
have no rule by which remedies may be certainly selected. 
If the remedy acts well, continue it; if not, use some other. 
No one remedy should be continued more than two or three 
weeks at a time. Sulphate of copper sometimes acts well, 
but it will occasionally cause considerable irritation, and it 
has an excess of astringent action not always easy to man- 
age. Use it in solutions of two to four grains to the ounce 
of water, or it may sometimes be applied in substance, but 
in the latter instance the part should be touched very light- 
ly, and only momentarily. Applications to the mouth of 
the Eustachian tube may ordinarily be made every second 
day. Some of the severer remedies may cause so much re- 
action as not to allow of a repetition under three or four 
days. If at any time the Eustachian tube closes up for a 
few days, the application has probably been of excessive 
strength, and a weaker effect must be subsequently sought 
for. On the other hand, if the tube still continues to sup- 
ply insufficient air to the tympanum, known by the evanes- 
cent effect of inflation on the hearing, it is well to increase 
the strength of our remedies. I have repeatedly made ap- 
plications to the tube of a thirty or forty grain solution of 
arg. nit. without success, when on changing to an eighty- 
grain solution — using only a drop or two in the faucial ca- 
theter — the good effect at once became apparent. A too 
weak solution is just as much to be avoided as the opposite. 
The toleration of a given patient always requires to be 
very carefully studied. I have discussed this point more 
fully while on the subject of acute catarrh of the tympanum. 
Many of the milder remedies suggested may be used daily. 
I sometimes give the patient the carbolic-acid solution to 
throw into the nostrils once or twice a day, using for this 
purpose the atropine dropper, the sick feeder, or in some 
of the more skilled, a Warner's nasal syringe (see Index), 
the nozzle of which is passed behind the velum. If at any 
time a coryza is produced by the applications, they have 
been too strong, or have been injected too far upward, ap- 
proaching or entering the frontal sinus by means of the in- 
fundibulum. All applications should be warmed, except 
those used in very small quantities. If the discharge be- 
comes thicker after an application, too much irritation has 
been produced. A thick discharge, under proper treat- 
ment, should become thinner and diminished in quantity. 



MANAGEMENT OF THE NASO-PHARYNX. 20g 

an unnaturally dry membrane should secrete more freely, 
and become moist. If the patient should sneeze after a cer- 
tain remedy, and show other symptoms of continued irri- 
tation of the naso-pharynx, the treatment is not properly 
borne. If the patient is doing well, the parts are likely to 
feel better and the hearing should cease to be variable, and 
the inflations should not be required after a few weeks, to 
maintain the hearing at its maximum standard. 

Of the Management of the Naso-Pharyngeal Space in Chronic 
Aural Catarrh. — The first indication is to thoroughly cleanse 
the part. As the nasal douche, first devised by E. H. Weber, 
and in England known as Thudicum's, has become popular 
among the profession, I must needs speak of it, although I 
do not often employ it, for the reason that water is some- 
times sent into the ear by its use, causing occasionally vio- 
lent inflammation of the tympanum, with rupture of the 
drum membrane and even extension to the mastoid cells. 
This douche is based on the principle that if water is forced 
into one nostril it will pass out of the other without enter- 
ing the lower pharyngeal space. The contact of the water 
with the hanging palate produces a reflex excitation, which 
causes it to fall back upon the posterior wall of the phar- 
ynx, shutting off the upper from the lower pharyngeal 
space. This movement is also assisted by somewhat rapid 
and continuous mouth respiration, or if the patient holds 
his breath a similar result follows. In order to avoid acci- 
dents to the ear, the vessel holding the water should be 
only high enough to allow of a stream to pass through the 
nostrils. It is not advisable to have it higher than the 
forehead. The fluid used may be salt, one drachm, and 
water, a pint, always warm — about the temperature of the 
water used in syringing the ear. Be careful not to force 
fluid into the frontal sinuses, by not allowing the patient to 
incline the head forward more than a very little, if at all. 
During the operation the patient should not be in the least 
disturbed or excited, lest he cough, make an effort to sneeze 
or swallow, when the fluid would very likely be forced into 
the middle ear. Before commencing this irrigation, observe 
whether both nostrils are free; in case one only is free, the 
douche, if used at all, must be made to enter through the 
partially occluded nostril. After using the douche, unless it 
be very warm weather, the patient should remain a few 
minutes in a warm room. I would not approve of passing 
a large quantity of water through the nostrils at a sitting 



2IO DISEASES OF THE EAR. 

— just enough to fairly cleanse them; perhaps twelve to 
twenty ounces, although I have heard enthusiastic laryn- 
gologists speak of the perfect safety of passing unlimited 
quantities through them. For instance, one of those gen- 
tlemen said he had sent barrels of salt water through the nos- 
trils, and he believed that a large quantity acted curatively, 
and cleansed with greater thoroughness. There is no doubt 
but that the irrigation acts pleasantly in removing secre- 
tion, especially when the nostrils are somewhat dry and 
" gummed up" with thickened mucus, as one of my pa- 
tients felicitously described it, but whether it acts as a cor- 
rector of abnormal mucous secretion is a question in my 
mind. I am aware that any mode of injecting the nares, 
whether in front or in the rear, is liable to cause fluid to 
enter the tympanic cavities. In the cases Dr. Roosa tabu- 
lated in his work on the ear, occurs one of my own, where 
a suppurative otitis resulted from my use of the douche. 
In this case I think the douche was properly used, the pa- 
tient, however, was not highly intelligent, and it is possible 
enough that he himself did something which interfered 
with the proper action of the douche. These conditions, 
however, are certainly too exacting to permit of patients 
using it themselves. I recently had a patient from the 
country who, without any interrogations from me, volun- 
teered the information that the doctors there had recom- 
mended the nasal douche, and many people had become 
deaf in consequence. 

In douching a patient I would throw in only enough of 
the fluid to dislodge the accumulation; stopping from time 
to time to see if the patient himself could not dislodge any 
remaining collection. Other means for cleansing the nos- 
trils may be used, and I decidedly prefer the catarrh 
syringe, throwing up a larger or smaller quantity according 
to the amount of collection to be removed. The practice 
of snuffing up salt water into the nostrils I do not like, hav- 
ing observed it to pass into the middle ear, but so far 
without doing harm. Pouring the fluid into the anterior 
nostrils by any convenient vessel is a good method, al- 
though I have known fluid thus to pass into the tympa- 
num. 

A medical gentleman of this town was some time since 
injecting his nostrils by means of a Davidson syringe, with 
warm salt-and-water, in a gentle, cautious manner, when 
he suddenly dropped to the floor in a faint^ in consequence 



TREATMENT OF THE NASO-PHARYNX. 



211 



of the fluid passing into his ears; he, however, soon re- 
covered. Forcing even warm salt water into the tympanic 
cavities is sometimes a serious matter. 

What I recently said under the heading of Management 
of the Eustachian tubes applies with equal force here: Re- 
move collections from the throat by the aid of the patient, 
as far as possible, by stimulating injections, or by the 
smallest amount of salt-water injections that will suffice to 
remove the masses. I suppose spraying the nostrils both 
anteriorly and posteriorly with salt-and-water is the mild- 
est possible mode of removing secretion from the naso- 
pharynx, aided also when practicable by the patient's own 
efforts. The general condition of redness of the naso- 

J'zy J. r 




Fig. 55. — Newman's Spray Producer. 

pharynx is met by the astringent applications mentioned 
when speaking of the Eustachian tube. The spray may be 
used both anteriorly and posteriorly. In spraying the nos- 
trils a minute funnel may be inserted, having an expanded 
portion, which may catch any excess of spray. Fig. 55 
shows Newman's spray-producer, and Fig. 56 represents 
Sass's spray instrument as it is propelled by compressed 
air. No applications to the nostrils should excite symp- 
toms of coryza or any prolonged irritation. Whenever red- 
dish or granular patches appear in the nostrils, they should 
be touched with a forty to eighty gr. solution of nitrate of sil- 



2l2 



DISEASES OF THE EAR. 



ver. I have also sometimes found the saturated solution of 
carbolic acid to do well. These reddish spots are often 
covered by an incrustation of catarrhal secretion, which 
clings tenaciously to the part, and often causes laceration 
and bleeding on being forcibly removed. If the nostril is 
anointed with vaseline several times a day, or, in case that 
irritates, with a little freshly prepared mutton suet, the 
crusts will form much more slowly, and often not at all. 
These patients occasionally have minute patches of herpetic 
vesicles form here and there on the lining of the nostrils, 
near the outer orifice. Both of these conditions are best 
treated by brushing on a rather strong solution of nitrate 
of silver, one of thirty to sixty grs. to. the ounce, or tr. of 




Fig. 56.— Sass's Spray Instrument with Gompressed Air Apparatus. 

iodine often acts well. For the general catarrhal condition 
of the naso-pharynx, powders properly medicated are often 
blown in, both posteriorly and in front, by an instrument 
here figured, and called a powder-blower. This was de- 
vised by Dr. A. H. Smith, of New York. (See Fig. 57.) It is 
well known that injecting the nostrils with a fluid is often 
very irritating, exciting coryza, sometimes causing severe 
headaches, with a feeling of fulness in the frontal sinus. 
The advocates of the powder method of treatment claim 
that the latter produces no unpleasant symptoms of this 
kind. I have used the powder only a little, and have a 
general feeling that it somewhat lacked in effectiveness. 
The active remedy in an ounce of the powder may be of 



TREATMENT OF THE NASO-PHARYNX. 



213 



somewhat greater proportion than where water is used. 
For instance, the nitrate of silver powder, frequently used, 
is made up thus: B. Arg. nit. gr. xx.; bismuth subnit., 
q.s. ft. fi; potass, sulph., 3 ij. This would correspond to 
about a twelve or fifteen gr. sol. of arg. nit. in water. The 
sulph. potass, is for the purpose of facilitating the reduc- 
tion of the mass to a sufficiently fine powder. The tubes 
used are made of hard rubber, but any person may extem- 
porize an instrument using glass tubing instead of rubber. 
The tip for turning in any direction cannot be made of glass. 
It is of the highest importance to keep the nostrils free, so 
that mouth respiration may be avoided. It is not always 
easy to ensure a free passage for air through both nostrils 
simultaneously. I have known many patients who usually 
had only one nostril at a time open, the trouble constantly 
changing from one to the other and back again. Lying in 
bed on one side will render the lower nostril obstructed 




Fig. 57.— A. H. Smith's Powder-Blower. 

and the upper one free, the condition being reversed on turn- 
ing to the opposite side. The tendency of this tissue (the mucous 
lining and the submucosa) to suddenly become engorged with 
blood, and swell considerably, presenting many of the charac- 
teristics of erectile tissue, has already been alluded to. This 
symptom is not easy to manage. Some nervous patients are 
likely to suffer from it when anything disturbs them greatly, or 
if excessively fatigued. To such a nervous stimulant would be 
beneficial in restoring a patulous condition of the nostrils. A 
four per cent, solution of cocaine in water poured on to a 
bit of cotton and passed up the nostril often affords great re- 
lief. Whatever growths obstruct these passages must be re- 
moved. Usually a mucous or fibrous polypus will be the 
variety found in this region. These may be removed by 
forceps, snare £craseur, galvano-cautery, or electrolysis. 
About the same rule obtains here as in the removal of aural 



214 DISEASES OF THE EAR. 

polpyi. What remains of the pedicle of the polyp should 
be cauterized. Other tumors of this region, malignant or 
benign, may be removed by a somewhat formidable surgi- 
cal operation, as removing a portion of the superior max- 
illa, a part of the palate bone, etc. These, however, come 
more in the domain of general surgery. Often, in old cases 
of naso-phar)mgeal catarrh, the mucous lining of the nares, 
with the submucous connective tissue, become so hyper- 
trophic as to occlude the nostrils. This is more likely to 
be the case with the parts covering the turbinated bones, 
especially of the middle and inferior. No amount of stimu- 
lation and cauterization will in certain cases cause this con- 
dition to disappear, and a variety of operations have been 
resorted to for their removal. 

Dr. A. H. Smith, of New York, has devised an instru- 
ment for this purpose, which he calls a cannula scissors (Fig. 
58), which in a very effective and not violent manner re- 
moves these hypertrophic swellings. Herewith is presented 




Fig. 58.— Smith's Cannula Scissors. 

the doctor's description of the instrument from The Pla?iet : 
" The instrument consists essentially of two canulae with 
closed rounded ends, one canula revolving within the other. 
One half of the circumference of each canula is cut away 
for the distance of one and a half inches from the distal ex- 
tremity, on a line somewhat slanting. The cut edges of 
the outer canula are brought to^ a knife-edge, while those 
of the inner canula are finely serrated. This part of the 
inner and outer canulae, respectively, represents the two 
blades of the scissors. When the inner canula is so placed 
that it corresponds with the outer one the scissors are open; 
when it is turned half round the scissors are closed. The 
slant given to the cutting edges insures a scissor action." 

"At the opposite end, the inner tube projects beyond the 
outer one, and is furnished with a milled head, by which it 
is revolved." 

"The instrument is introduced into the nose open, that 
is to say, with the inner blade lying in the concavity of the 



OPERATIONS ON THE NARES. 21 5 

outer one, and the open side is pressed firmly against the 
part to be removed. Whatever tissue is contained in the 
hollow of the inner blade is cut off when a half turn is 
given to the milled head." 

" The removal of hypertrophied tissue from the turbinat- 
ed bone by this method is followed by hemorrhage, which 
may be profuse, but is usually easily controlled. The re- 
sults in cases of obstinate catarrh are often extremely sat- 
isfactory." 

The denuded surface subsequently becomes covered by a 
fine cicatricial membrane doing duty in the place of nor- 
mal mucous membrane quite satisfactorily. 

Also, for the purpose of reducing the swelling, so that the 
nostrils may become pervious, tubes have been inserted 
into them and allowed to remain from a few hours to sev- 
eral days, if not provocative of undue irritation. Bougies 
of laminaria are occasionally used, but as they expand 
rather rapidly, and sometimes unevenly, much irritation is 
caused on removing them, especially as the laminaria is not 
very smooth, and may lacerate the delicate mucous lining. 
Cocaine may relieve this irritation. Any ulcerated places in 
the nostrils may be touched with a caustic, as arg. nit., carbolic 
acid in crystals, nitric acid, or acid nitrate of mercury. The 
probability of some of these ulcerations being specific will sug- 
gest appropriate constitutional measures. 

A variety of ostotic processes greatly narrow or alto- 
gether close the nares. These require removal. This is 
now frequently done by the dental engine and drills. The 
ostosis may be perforated, and a sufficient aperture made 
for purposes of nasal respiration, and cleansing the nostrils 
by blowing the nose, etc. A case of my own, published in 
the Transactions of the New York State Medical Society 
for 1881, illustrates this point. The patient, a man 44 
years of age, could not force a particle of air through his 
right nostril. The catarrhal collection could not be blown 
out, and was a source of great discomfort to him, as he 
could cleanse the nostril only by using the syringe. There 
was considerable deafness on the side of the affected nos- 
tril. Anteriorly I could see nothing, but a probe struck 
an obstruction deep in the nostril. Rhinoscopy revealed 
nothing. I then passed my finger behind the velum, and 
by a strong effort pushed it forward into the posterior 
nares of the right side for the distance of half an inch, 
when it touched a solid wall of bone. By measuring the 
14 



2l6 DISEASES OF THE EAR. 

length of each nostril, and estimating the distance of this 
obstruction from the entrance to the posterior nares, I 
could determine accurately its depth in the canal, and that 
it was of no great thickness. I attempted its removal in 
the line of the inferior meatus, knowing it to be too diffi- 
cult to remove the whole of it, neither was it necessary. I 
at first used a number of drills of different shapes, which 
enabled me to perforate the bone, but did not permit of 
enlargement of the aperture. I then had constructed what 
is known among dentists as a cross-cut burr drill, the head 
having an almond shape, and as large as could be con- 
veniently introduced into the nostril — about 2-J lines in 
diameter. It required to be covered with vaseline, as the 
sharp edges of the burr would catch the mucous membrane 
of the nostril, and prevent its introduction without lacer- 
ation. In three sittings I enlarged the opening sufficiently 

A 





a 

Fig. 59. — Jarvis's Wire Snake Ecraseur. 

for moderately difficult respiration through that nostril. 
After each operation the opening at first would be quite 
free, and by the next day it would be nearly closed, but 
would open again in a day or two more. 

A more usual method, however, for removing these 
obstructions is to use a rather fine drill and make successive 
borings in the periphery of the mass until a central portion 
is cut off, when this may easily be extracted by forceps 
(Goodwillie). The objection to a large-sized drill is that the 
power is insufficient to effectively propel it. The Morrison 
engine is usually used, although a modification has been 
made by Dr. White. A somewhat more powerful appa- 
ratus, called the Elliott suspension dental engine, is, accord- 
ing to Dr. Arthur Mathewson, of Brooklyn, superior to the 
one ordinarily in use. In the removal of adenoid growths from 
the vault of the pharynx the same procedures are employed as 
in the management of aural polypi. Politzer thinks that 
cauterization is sufficient to dispose of these, but the weight 
of authority is against him. Forcible removal by some 



OPERATIONS ON THE NARES. 217 

mechanical appliance seems strongly indicated. Where a 
delicate snare can be passed through the nostril and looped 
upon the growths by the aid of the fingers passed into the 
upper pharynx, the extraction becomes an easy matter. 
For this purpose Jarvis's snare ecraseur (Fig. 59) is valu- 
able. Sometimes by passing the finger behind the velum 
and scraping or tearing the growths, if not too fibrous, and 
if they are sufficiently pedunculated, they may be removed. 




Fig. 60. — Forceps for the Removal of Adenoid Growths. 

An instrument resembling a lithotrite (Burnett) may de- 
stroy them by crushing, when they shrivel up and dis- 
appear, or are removed by sloughing. This is not, how- 
ever, a very reliable method. Sometimes an instrument 
resembling Buck's curette for the removal of aural polypi 
may act serviceably here. 

Forceps passed through the nostrils, if of sufficient deli- 




J. KLiM)LR^—CO. 
Fig. 61.— Bellocq's Cannula. 

cacy and strength, act very admirably. Dr. Noyes' polyp 
forceps, elsewhere figured, are very strong in the jaws, and 
if a magic catch be attached to the handle so as to allow of 
twisting the growths, they may thus be removed. The for- 
ceps may be introduced at once, and in the possibly large 
multitude of growths one may be easily caught by the 
sense of feeling to guide. Afterwards the finger passed 
behind the velum, will cause the growths to be pushed into 



218 DISEASES OF THE EAR. 

the bite of the forceps. By using Zaufal's speculum, a 
single growth may be brought under inspection, and its 
peduncle sought out and destroyed by nitric acid or acid 
nitrate of mercury, or the nitrate of silver. When employ- 
ing the more powerful caustics, the smallest quantity must 
be used, and no other points touched than the growths. 
After the latter have been removed, cauterization of the 
bases may be necessary. Occasionally it will be possible 
to catch the growths from behind the velum by means of a 
pair of forceps having a short curve similar to Mackenzie's 
laryngeal forceps (Fig. 60), or a wire loop may be passed 
from the throat through the nostrils by the aid of Bellocq's 
cannula (Fig. 61), the wire first being attached to a small 
cord passed from the nostril to the throat by the aid of the 
cannula, and this to be attached to the Jarvis instrument. 
By this manoeuvre the loop is readily passed around the 
growths. These growths often obstruct the Eustachian 
tube ; but if they do not there is a catarrhal condition per- 
petuated by their presence which may aggravate any ear 
symptoms. It is well to attack only one or two growths at 
a sitting, as considerable disturbance is likely to result 
from the operations. The same rule may be applied in 
removing granulations or polypi from the same region. 
The galvano-cautery may be used. (See Fig. 62, represent- 
ing Schroetter's instrument, with all the necessary attach- 
ments.) The objection to it is that it is an expensive mode, 
and the instrument gives considerable trouble in keeping it 
in repair, and to operate effectively the wire loop must 
generally be used, which involves the same difficulty as in 
the ordinary snare. Sometimes the porcelain burner or the 
knife may be used. There is this gained over the snare, 
however: it cuts through the growth without violence, and 
leaves a surface already cauterized, from which there is 
little or no trouble with hemorrhage, which in other 
methods is likely to occasion embarrassment. The uvula 
often requires attention. When it is so elongated as to 
impinge upon the base of the tongue, it excites coughing 
and aggravates the catarrhal condition. Before attempt- 
ing its removal, an astringent gargle may be employed; if 
this fails it may be pencilled every day or two with a strong 
solution of nitrate of silver, sixty or eighty grains to the 
ounce of water, or nitric acid may be cautiously used, or 
even the acid nitrate of mercury. It is very tolerant of 
strong applications. 



SCHROETTERS GALVANO-CAUSTIC APPARATUS. 219 




Fig. 62.—^, snare; B, knife; C, porcelain burner; D, knife; E, Voltolini's knire- F. 
ligature carrier. The universal handle is attached at A ; The galvanic connections 
are made at g and /. 



220 DISEASES OF THE EAR. 

If this fails, then ablation must be practised. Catch the 
tip of the velum in the bite of the forceps, and divide it by 
a single stroke of a stout pair of scissors. The piece re- 
moved should be about one fourth of an inch in length. 
Frequently too much is removed, unnecessarily mutilating 
the organ; besides, the uvula becomes, after a little time, 
still shorter from natural shrinkage. 

For a few days after removal, a mildly astringent and 
emollient gargle may be used, as biborate of soda, chlorate 
of potass., etc. The velum sometimes suddenly swells to 
such a size as to fill the cleft in the pharynx and seriously 
interrupt respiration. This accident once occurred to me 
while making an application behind the velum of nitrate of 
silver by means of the pharyngeal syringe. In an instant 
the velum swelled to the size of one's finger, and the pa- 
tient was horrified to find that he could not breathe. To 
gain a few seconds time, I compelled him to breathe through 
the nose, what little was possible, when I immediately re- 
lieved him by making some dozen minute punctures in the 
velum with a Graefe's cataract knife. The uvula returned 
to nearly the normal size in from four to six minutes. 
This accident happened to me once besides this. I had 
made an application to the Eustachian tube of nitrate of 
silver, when I lacerated perhaps, the mucous membrane 
covering the velum. After this I performed Politzer's infla- 
tion, when suddenly the velum swelled as before described, 
and the patient fell to the floor, perhaps as much from 
fright as anything, and for a few seconds could not breathe 
at all. Relief was obtained as in the first instance and as 
suddenly. Dr. J. Solis Cohen, in his work on the throat, 
recommends cutting off the end of the velum in similar 
conditions. 

The lateral half arches, and adjacent parts are often of a 
more intense red color than other parts, which require spe- 
cial attention. I am in the habit of pencilling on a rather 
strong solution of arg. nit. or tr. iodine to meet this indica- 
tion. When this congestion presents the appearance of a 
distinct red line at the border of the arches, a syphilitic in- 
fection may be suspected. 

The tonsils are often so swollen and hypertrophic as to 
require treatment. Very strong cauterization with arg. 
nit., nitric acid, or acid nitrate of mercury or chromic acid 
crystals, may be used to diminish the size. In order to 
accomplish anything, a large part of the surface of the 



TONSILLOTOMIES. 



221 



tonsil must be cauterized, which will be rather difficult to 
accomplish. If incisions are made in the tonsil previous to 
cauterization the effect will be greater. 




Fig. 63. — McKenzie's Modification of 
Physick's Tonsillotome. 



Fig. 64.— Mathieu's Tonsillotome. 



Dr. J. Solis Cohen, in his book on Diseases of the 
Throat, quotes Morrill Mackenzie to this effect: He uses 
on enlarged tonsils London paste, which is composed of 



222 DISEASES OF THE EAR. 

equal parts of caustic soda and hydrated lime, a portion of 
which is moistened with water at the time of its employ- 
ment. The caustic is applied with a rod of aluminium 
wire. The application must be made many times to suffi- 
ciently destroy the excess of development of the tonsil. 

It is much less painful than caustic potash or Vienna 
paste, and causes less reaction. The galvano-cautery, by 
means of the loop, answers well for removing a consider- 
able piece of the tonsil. It is passed over the latter, and as 
it becomes heated it is tightened, when it readily cuts its 
way through with little or no bleeding. Electrolysis is a 
good method for diminishing the size of the tumor, but it 
takes many sittings for its accomplishment. Before doing 
an important operation such as ablation, it is well to re- 
member that enlarged tonsils are likely to diminish in size 
at the age of puberty. If an operation for removal is de- 
cided upon, McKenzie's modification of Physick's tonsillo- 
tome is perhaps the best instrument to use (Fig. 63), or 
Mathieu's (Fig. 64) is a most elegant instrument. It is ad- 
visable, if an operation be done at all, to remove a good- 
sized piece, sufficient to extend to the pillars of the fauces. 
In the removal considerable hemorrhage may occur, even 
in some rare cases to a fatal result, but ordinarily nothing 
is to be apprehended from the bleeding. The main points 
to be observed are, to avoid a fold of mucous membrane 
lying somewhat in front of the tonsil, called the anterior 
faucial fold, or the palato-glossal fold, which by being in- 
cised in the removal of the tonsil may bleed very freely, 
besides causing an unpleasant sore throat subsequently, 
and the avoidance of removing the tonsil too deeply so as 
to reach the branches of the internal carotid, or ascending 
pharyngeal arteries. This may also be obviated by draw- 
ing the tonsil away from its position, and avoiding in the in- 
cision anything except the tonsil itself. In children use 
the tonsillotome, but in adults a good method is to catch the 
tonsil with a properly constructed forceps, and remove it by 
cutting with a probe-pointed bistoury, commencing above 
and cutting downward, backward, and terminating the in- 
cision by coming out forwards. The resulting hemorr- 
hage may be controlled by pieces of ice held in the mouth, 
or a piece of ice held in forceps pressed against the part, 
or by simple pressure with the ringers or a sponge on a 
holder, against the bleeding surface. The persulphate of 
iron is a good styptic, but it coagulates the blood and 



REMOVAL OF THE TONSILS. 223 

makes a dark-looking mass, which obstructs the throat and 
is troublesome to remove. The best plan is to carefully 
examine the wound and if any artery is found to be di- 
vided, or if the blood oozes considerably from any particu- 
lar point, pass in a pair of forceps and twist the tissue in 
the expectation of including the cut end of the artery, when 
it (the bleeding) will be easily arrested. Injecting water 
as hot as may be borne is a good expedient. It is rarely 
that the common carotid or the internal carotid require 
ligation to arrest the hemorrhage. After the removal of a 
tonsil, bland and fluid food should be given for a few days, 
and gargles of salt-and-water, biborate of soda or chlorate 
of potassa, may be used. It is well to remember that hem- 
orrhages may occur after the first or second day and to be 
on guard for such an accident. 

Applications to the upper pharyngeal space may be made 
in a variety of ways. I have for years discarded the pro- 
bang, brush, or cotton on a holder, for reasons sufficiently 
discussed heretofore. The spray instrument, with a tip 
for throwing the spray upward, is indicated. The glass 
instruments I do not use in this connection, for the follow- 
ing reasons: the tip is liable to be broken off, but if in some 
cases this objection does not exist, there is another reason 
— the tip will not hook behind the velum, and if the latter 
chances to be thrown backward against the posterior wall, 
as often happens, no spray can enter the posterior pharyn- 
geal space. In using the hard rubber instrument the tip 
is sufficiently long to pass behind the uvula, and the spray 
is readily applied. If the uvula is strongly drawn against 
the posterior wall it may catch the tip of the spray in- 
strument, and close it so that no spray can be produced; 
this condition is met by moving the instrument from 
side to side, or by a forward and backward movement, 
which disengages it from the velum and a spray is easily 
formed. In rapid dispensary work I never hold the instru- 
ment perfectly still, but keep it moving constantly. It is 
easily known when a proper spray is made by the soft pe- 
culiar sound accompanying its production. Next to the 
spray instrument I prefer the posterior-nasal syringe, as has 
been before indicated. Use the same remedies and in the 
same manner as described under the head of Applications 
to the Eustachian Tube. The posterior wall of the pharynx 
will often need somewhat strong applications of the nitrate 
of silver. The brush, cotton-holder, or porte-caustique, with 



224 DISEASES OF THE EAR. 

the mitigated or clear stick, may be used in making appli- 
cations to this part. It may be well to cauterize only a 
small spot at a sitting; be guided, however, by the patient's 
toleration of the remedies. I do not forget that sufficient 
cauterization to cause an eschar may destroy mucous mem- 
brane, and lead to the development of cicatricial tissue, 
having no glands to moisten the part. Tr. iodine is a 
good application when cicatricial changes have occurred, 
but it may sometimes be painful. The whole naso-phar- 
ynx, when swollen, perhaps pale, succulent, and relaxed, 
will often be much benefited by tannin 3 i., glycerine, § i., 
brushed on the posterior wall, and injected behind the ve- 
lum. Hypertrophic glands may be cauterized by a satu- 
rated solution of arg. nit., or the stick. Occasionally the 
part may be brushed with a solution of carbolic acid, one 
drachm to the ounce of water. The pain from the applica- 
tion is quite momentary. Occasionally the applications 
of nitrate of silver to the hypertrophic glands may produce 
no effect; in that event the latter may be cut across and 
the caustic in substance maybe insinuated into the incision. 
In the advanced stage of chronic pharyngitis, called pharyn- 
gitis sicca, where the mucous membrane is thin, dry, shiny, 
and devoid of glands from atrophy, the treatment is pal- 
liative. The glands cannot be restored and the moistening 
of the part must be done by applications. For this pur- 
pose almost any of the stimulating lozenges or so-called 
troches in the market are useful, such as salicylic acid, 
carbolized or chlorate of potassa lozenges. Applications to 
the posterior wall of glycerine or vaseline will diminish 
the dryness and sense of heat. In speaking, such patients 
will find that moistening the throat with a draft of 
water frequently has a pleasant effect. Internal remedies 
calculated to act on the mucous secretion may often do 
good and benefit the catarrh in a general way. These are 
cubebs, copaiba, muriate of ammonia, or iodide of potas- 
sium. Inhalation of steam often has a pleasant temporary 
effect. 

Gargles for chronic pharyngitis are beneficial in a variety 
of ways. It is true that very little of the gargle passes be- 
hind the velum, but it is a well recognized fact, that if the 
parts which are in sight are improved in condition, the good 
effects almost certainly extend to those adjacent. A very 
important factor in the results of gargling is the effect on 
the muscles of the region, notably those of the soft palate 



GARGLES IN PHARYNGITIS. 225 

and Eustachian tubes. In chronic catarrh of the pharynx, 
the mucous membrane is often thickened, and it may be 
accompanied by infiltration of the underlying connective 
tissue. Where this changed mucous membrane lies over 
muscles, it interferes with their action, and atrophic de- 
generation may result as a consequence. Again, the mu- 
cous membrane covering the muscles is peculiarly rich in 
glands, which are located upon and between the muscular 
fibres, the latter in part surrounding them, according to 
Von Troltsch (Roosa's translation), so that, whenever a 
muscle contracts, the glands are more or less pressed upon, 
and when obstructions to the latter exist, their contents are 
often squeezed out by this muscular contraction. Thus, 
the condition of muscles and mucous membrane react on 
one another. One of the best means of improving the 
faulty muscular condition, according to Von Troltsch (loc. 
cit.), is by a species of gymnastic training. This is accom- 
plished by gargling. It should not be done in the usual 
manner ; the patient should throw the head very far back- 
ward, almost as though he were lying down ; make a par- 
tial attempt at swallowing, but do not complete the act ; 
expire very forcibly and produce a loud rumbling phonation; 
endeavor to bring into action all the muscles of the throat 
during the gargling. This may be done several times in a 
day. 

The kind of gargle to use may be selected as follows : At 
first simple water, or plain carbonic acid water, may be 
used ; the rinsing of the part and the gymnastic effect being 
the main object gained in using these remedies. Chlorate 
of potash in saturated solution, is an old and valuable 
gargle. Carbolic acid, one drachm to the pint of water, 
with or without tannin, acts satisfactorily. Tr. of Iodine 
and Iodide of Potass., of each one drachm to the pint of 
water, with a half-ounce of Spts. Vin. Gal., is a gargle 
strongly recommended by Von Troltsch. Alum, one drachm 
to the pint of water, with a little alcoholic addition, may 
be recommended. A very old remedy is alum in an infusion 
of sage tea. The latter disguises the taste of the alum. 
We may go on adding to our gargles, by selecting any 
mild remedy suitable for the treatment of naso-pharyngeal 
catarrh. 

In the constitutional treatment, I simply repeat what has al- 
ready been said, when treating of acute catarrh. Whatever 
lowers the tone of the general system is damaging to a 



226 DISEASES OF THE EAR. 

catarrhal patient, so every possible means must be resorted 
to which may accrue to the patient's general well-being. 
The functions of the skin need special attention, to compen- 
sate in part for incomplete function of mucous membranes. 
Bathing frequently, with friction of the skin, by means of 
a crash towel, hair mittens, flesh brush, etc., will naturally 
suggest itself as appropriate management for this indica- 
tion. Means for resisting the pernicious atmospheric and 
climatic influences need to be resorted to and are detailed 
under the head of Prophylaxis, in the article on Acute 
Catarrh. 

Where the muscles of the Eustachian tube are in a relaxed con- 
dition, or the innervation is insufficient, electricity may be em- 
ployed for the restoration, as far as may be, of these 
muscles to a normal energy of action. Many methods 
may be practised. On the whole, the constant current will 
be preferable to Faradism. The positive pole may have an 
extension resembling an Eustachian catheter, to be applied 
to the orifice of the tube, while the negative pole is applied 
by means of a moist sponge to the meatus externus. 

ACUTE PURULENT INFLAMMATION OF THE TYMPANUM. 

The symptoms are as follows : The patient is attacked 
with a pain in the ear, which may have been preceded by in- 
flammation of the naso-pharynx, or the disease may have in- 
vaded the ear from the direction of the membrana. In either 
case, J>ain is the most prominent symptom. It is charac- 
terized by a feeling of pressure or fulness in the tympanum, 
which in the severer forms goes on increasing until the 
suffering is well-nigh unendurable. It is accompanied by 
the rhythmical pounding of the heart beats, which still fur- 
ther aggravates the suffering of the patient. This goes on 
from one to several hours until relief is experienced, 
usually by the rupture of the membrane and the discharge 
from the ear. Previous to this, however, the patient ex- 
periences certain prolonged crackling or hissing sounds 
accompanied by a sharp pain which seems to dart through 
the depths of the ear. This is repeated a number of times 
until the discharge is well established and the pain re- 
lieved. The whole side of the head may be tender on pres- 
sure and painful. If the disease commences in the throat, 
the pain may be easily followed up the Eustachian tube, the 
cavity of the ear will begin to feel oppressed and full, and 



SYMPTOMS OF ACUTE PURULENT CATARRH. 22J 

ere long the disease will have wholly invaded the tym- 
panum. This pain is aggravated by opening the mouth, 
by coughing and sneezing, and by the act of deglutition. 
Any movement of the auricle causes pain. It is worse 
while lying down than when sitting upright for hydrostatic 
reasons undoubtedly. The pain oftener comes on in the 
after part of the day, when the patient is fatigued, or more 
likely, perhaps, in the night, possibly towards morning. 
After a first attack, relapse may occur a number of times, if 
the symptoms are not promptly met at the outset. Some- 
times the pain may be of the dull, heavy kind, with less 
fulness than usual. This is occasionally the case when 
leeches fail to effect relief, or where the tympanum is full 
of fluid. There are apparent exceptions to the general 
proposition that pain precedes the discharge. In a few in- 
stances, if the patient is somewhat unobservant, a discharge 
may make its appearance without any pain having been 
noticed. This is more likely to be the case in tuberculous 
subjects. If, however, such patients had carefully observed 
their symptoms, undoubtedly a feeling of fulness or a slight 
throbbing in the ear would have been noticed. In every 
severe attack of acute otitis media, we are likely to have 
the canal much swollen, tender and often completely closed. 
Together with the pain, we have decided constitutional symp- 
toms — fever, possibly delirium, and in children sometimes 
convulsions. The patient is very likely to be ill in bed, and 
if the pain continues for a considerable time, the face, by 
its distressed and haggard expression, reveals the severe 
nature of the affection. 

The discharge does not make its appearance at first, usually 
not until the membrane is perforated. This may be a mixture 
of serum, mucus, pus, and blood. Its most constant charac- 
teristic, however, is pus, which gives to the disease its name. 
Other subdivisions of otitis, determined more exactly by the 
character of the discharge, might be given, as otitis media, 
serosa, haemorrhagica, etc. The severer the attack the more is 
the discharge likely to be purulent or sanguinolent, and to be 
excessive in quantity. After a few days, if the meatus becomes 
macerated and loses its epidermis in consequence of the macer- 
ation and excoriation incident to the discharge, the latter 
may become somewhat flaky from the epidermic admixture. 
As the patient convalesces the discharge grows thinner. The 
hearing may be at first unnaturally acute, and loud sounds will 
become painfully distinct, but subsequently deafness may be- 



228 DISEASES OF THE EAR. 

come profound and even bone conduction may be nearly ob- 
literated. Tinnitus aurium adds to the patient's discomfort, 
and it may be accompanied by giddiness, nausea, and symptoms 
resembling Meniere's disease. The patient hears his own 
voice with unpleasant distinctness (autophony), provided the 
bone conduction be good, causing a very unpleasant hollow 
reverberation within the skull. 2'he appearances on inspectio?i 
are, at first, as follows : In a severe case nothing may be seen 
but a canal so swollen as to be obliterated. If, however, the 
drum membrane be visible before there is a discharge, there will 
be more or less redness. The light spot, the malleus handle, 
the short process, the folds, and all the landmarks may be 
recognized, and the redness of the membrane may be seen 
along the handle of the malleus and about the short process, 
and possibly the periphery may be injected, or the whole of 
the membrane may be of an uniform red color, resembling raw 
beef. Naturally in this state none of the " landmarks" of the 
membrane are visible. If the tympanum is full of fluid, as pus, 
blood and mucus, the membrane will be seen bulging to a 
greater or less extent. The umbo may perhaps still be seen, 
as the malleus handle has a strong disinclination to be pushed 
outward, and the membrane may be seen bulging in front and 
behind it, but more frequently the prominence will be above 
and behind, and so near to the canal wall as to seem to be a 
part of the meatus. The apex of the prominence may show 
a faint light reflex, if the polish of the membrane still re- 
mains. When the peif oration has taken place it may be known 
by several signs : the perforation may be seen, but frequently 
not, a jagged spot or line only indicating its site. Again, 
after carefully cleaning the ear, if there appears a light spot 
of small size and of great brightness, it undoubtedly is a re- 
flex from fluid which has been caught by capillary attraction 
in a fissure-like perforation. If there is seen a pulsation in the 
membrane, there is very little doubt of a perforation. This 
may be explained on the theory that a considerable sized 
blood-vessel has been partly uncovered by the break in the 
membrane, and its pulsations become visible. If, on inspec- 
tion, during inflation, fluid or bubbles of air are seen issuing 
from the membrane, there is no doubt of perforation. When 
the fluid is all blown out of the tympanum, the perforation 
whistle is heard. If the ear has been carefully cleaned, and a 
few minutes subsequently there is again a quantity of fluid on 
the membrane, there probably is a perforation, as the external 
ear is very infrequently capable of secreting so rapidly. Often, 



DIAGNOSIS OF A PERFORATED MEMBRANA. 



229 



by using a diagnostic tube during inflation, a very faint squeak- 
ing or hissing sound may indicate the fact of perforation. We 
will admit, however, the possibility of eliciting a sound, pro- 
duced by air passing through the Rivinian fissure, although we 
have never satisfactorily demonstrated the fact. 

The bulging of the membrane cannot always be determined 
by inspection. If it be touched by a probe, the peculiar sensa- 
tion elicited, of added depth to the tympanum, the result of the 
collection, will probably indicate the fact. 

By alternately drawing out and pushing in the air of the 
meatus by Siegle's otoscope (Fig. 65) the mobility of the mera- 




Fig. 65. — Single's Otoscope. 

brane will give us a hint as to whether the cavity contains fluid 
or is empty. As soon as the membrane has been perforated and 
the discharge has moistened the parts, the polish of the mem- 
brane will be destroyed and its translucency lost. Even in 
high degrees of congestion the red color will give place to the 
whitish gray appearance of a macerated epidermis. The latter 
is easily thrown off, and indeed often may be wiped away by 
the cotton used' in cleaning, when the red color of the con- 
gested fibrous layer of the membrane may be seen. 

Throat symptoms are usually present, and may be of any 
variety of acute inflammation from that of diphtheria and 
fevers, to the simplest form of naso-pharyngeal catarrh. Where 
the disease involves the tympanum from the direction of the 
meatus, there will not necessarily be any throat complications. 
It will readily occur to the reader that the angina from scarlet 
fever is peculiarly liable to cause this form of disease, and that 
of the greatest intensity. Many of the old cases of chronic 
suppurative otitis which are so intractable to treatment are 



230 DISEASES OF THE EAR. 

caused by scarlet fever. The otitis peculiar to typhus and 
typhoid al fevers will be treated of in another place. 

The duration of this disease is extremely variable. In a case 
of moderate severity, and properly treated, the pain is usually 
relieved at once or in the course of two or three days, while 
the discharge is likely to continue for from two to six weeks. 
With the cessation of the discharge the perforation usually 
heals promptly. 

In cases, perhaps improperly treated, or of unusual severity, 
the disease may continue for a much longer time. We have 
observed patients who have had attacks of pain every night or 
two for five or six weeks. Other cases, where the membrane 
fails to heal, continue on under the form of chronic suppura- 
tive otitis, and may last indefinitely. One point must not be 
lost sight of in determining the prognosis, to estimate how fre- 
quently relapses are likely to occur. If the patient is debili- 
tated and also is imprudent in exposure to inclement weather 
there will almost certainly be relapses. If the mastoid becomes 
involved it may be a long time before recovery takes place. 
If necrosis occurs it will render the case tedious. 

The prognosis is, on the whole, favorable. In a healthy adult, 
with proper treatment, the pain should be promptly relieved 
and the inflammation arrested, and the membrane healed with 
good, if not perfect, hearing. In children, after scarlet fever, 
it is not as likely to result in resolution and repair of mem- 
brane, and is frequently found involving the mastoid, and 
causing bone destruction. Brain complications are met with 
occasionally. Cerebral abscesses occur from the destruction 
of the bony septum between the brain and tympanum. Sep- 
ticaemia and pyaemia may result, as well as metastatic abscesses. 
Thrombosis of the sinuses in the vicinity of the ear sometimes 
is observed. 

Etiology. — The first fact we are impressed with in discussing 
the causes of this disease is that the patient has "caught cold" 
and has a sore throat, the throat affection antedating the ear 
symptoms, and, as has before been hinted, the pain and un- 
pleasant sensations are often found on only one side of the 
throat which soon invades the ear of the same side. Exposure 
of the ear directly to cold will excite an otitis without there 
necessarily being any throat symptoms. Listening at a key- 
hole will give a patient otitis consequent on the draft of air. 
Cold water introduced into the canal may cause an otitis, and 
in sea bathing it often does. When the patient goes under water 
a certain amount may get into the naso-pharynx, and in the 



CAUSES OF ACUTE PURULENT INFLAMMATION. 23 1 

disturbed respiration, coughing, sneezing, swallowing, and the 
like, water is forced up the Eustachian tubes into the tympa- 
num. It is true that in salt-water bathing the water is salt, but 
it is too salt, and it is cold. Besides this, the breakers may 
sometimes strike the side of the head and produce such a con- 
cussion upon the ear as to rupture the membrana tympani ; but 
in any event, inflammation of the tympanum may follow the 
introduction of cold water into the meatus. 

Many skin affections about the head and face may creep into 
the meatus and involve the tympanum. The tuberculous con- 
dition, with its throat complications, often induces suppurat- 
ive otitis. Tuberculous matter, in the tympanum or what is 
analogous to it, acts as a foreign body and excites inflam- 
mation. In Bright's disease of the kidneys, the diseased blood- 
vessels in the tympanum sometimes rupture and excite inflam- 
mation. Traumatism sometimes causes suppurative otitis. It 
is a well-known fact that the concussion upon the membrane 
of the tympanum, resulting from standing near a cannon when 
fired, will rupture the membrane, and sometimes excite a vio- 
lent otitis, although it is more likely to injure the labyrinth. 
The directions given by gunners to meet this difficulty, is to 
stand with the mouth wide open. The explanation of this is 
probably that the concussion falls equally upon both sides of 
the membrane. This phenomenon would cause us to suspect 
that the Eustachian tube is either habitually open, or is very 
easily forced. A box on the ear may, by suddenly compress- 
ing the air in the meatus, rupture the membrane and excite 
inflammation. Recently a boy came to me with an otitis 
which plainly pointed to the traumatism inflicted by a snow- 
ball which had been thrown by another boy, and had struck 
him full in the meatus, and had filled the latter with snow. 
In this case there was added to the traumatism the intense 
cold of the snow as an excitant to inflammation. Dr. Burnett, 
of Philadelphia, in his Treatise on the Ear, refers to a case 
where the disease was excited by a blow from a playing-ball 
thrown by a comrade. He explains the mode of the injury by 
the sudden compression of the air in the meatus, which, striking 
on the membrane, inflicted the injury. Another patient under 
my observation accidentally thrust a lead pencil into the meatus, 
its pointed extremity penetrated the membrane, and caused 
a violent purulent otitis, with loss of a portion of the mem- 
brane. He, however, recovered with a perfectly healed drum 
membrane and good hearing. The nasal douche has, I have 
not the least doubt, caused many attacks of otitis purulenta. 
15 



232 DISEASES OF THE EAR. 

The action of scarlet fever in developing otitis, is mainly 
through the throat, though occasionally the external meatus is 
first involved. This is usually a severe form of otitis, with a 
strong tendency to destruction of tissue. The labyrinth may 
also become implicated. It does not, however, in my opinion, 
differ in kind from other purulent inflammations of the middle 
ear. Nearly the same may be said in regard to the otitis of 
measles, but it is not as severe as the scarlatinous variety. 
Other fevers also cause otitis by throat complications. Pneu- 
monia sometimes causes otitis, especially in children. In them 
the patulous condition of the Eustachian tubes allows air to 
pass into the tympanum during the rapid respiration incident 
to this disease. The air being taken in rapidly and through 
the mouth, is not sufficiently warmed, and this alone may cause 
the otitis, besides the violence inflicted by the passage of air 
into the tympanum. It is not denied, however, that an angina 
in pneumonia may produce an otitis as in the same affection 
elsewhere. 

The diagnosis of this disease is mainly from acute catarrhal 
otitis. From this it may be distinguished by the presence of 
pus in the discharge ; by the constancy of perforation of the 
membrane and the tendency to its destruction; its greater 
severity, its symptoms of constitutional disturbance, and its 
tendency to become chronic unless cured by treatment. We 
regard this disease as the same in kind as the catarrhal, but- 
differing principally in its greater intensity. Otitis externa 
somewhat resembles this disease, and the differentiation has been 
given under the heading of the former. In small children it is 
very difficult to determine whether signs of distress manifested 
in a given case are dependent on ear trouble or on some other 
affection. There is violent crying ; the head may roll about 
as though there was brain trouble; there may be intolerance of 
light, and even convulsions; and whether the trouble be of the 
brain, the bowels, or the ear, is difficult to tell. It is true 
that if a good view of the membrana be obtained, it will proba- 
bly appear intensely red and perhaps bulging; but the parents 
do not usually think of having an examination made. After a 
time the discharge appears and the mystery is solved. 

In the treatment, the first indication is to relieve the pain. 
Fortunately, most of the means commonly used for this pur- 
pose tend also to subdue the inflammation. Abstraction of 
blood by leeches is perhaps en the whole the most potent rem- 
edy. From one to three leeches may be applied to the outer 
opening of the meatus, but preferably on the posterior face of 



TREATMENT OF ACUTE PURULENT OTITIS. 233 

the tragus. After the falling off of the leeches the bleeding 
may be allowed to continue for an hour unless the patient is 
completely relieved from pain, and there are special symptoms 
of depressed energy. We have usually found one or two 
leeches sufficient for our purpose. It is well to abstract only 
enough blood to relieve the pain, as the patient tends, in con- 
sequence of the grave nature of the disease, to rapidly become 
depressed. It is a good plan to repeat a single leech once in 
three or four hours, if the first gives insufficient relief. It may 
be necessary to repeat the leeching every one, two or three 
days to thoroughly deplete the engorged tympanum. As long 
as there is a feeling of fulness in the ear plainly pointing to 
hyperemia of the tympanum, it is well to repeat the leeching. 
The point at which the leech is applied seems to me important. 
It has been my experience, that a leech in the position previ- 
ously mentioned, accomplishes much more than when placed 
elsewhere. It is well not to allow the leech to bite on the 
cartilage of the concha or helix, for quite serious erysipelatous 
inflammation has resulted from such a leech bite. The man- 
agement of the leech requires skill and judgment. If some 
violence is used in the efforts to arrest the hemorrhage, the ear 
may again begin to throb and grow painful. Rholand's styp- 
tic cotton has been highly recommended for this purpose, but 
I have often seen it fail. It is well to touch the bites with a 
bit of cotton wound on a cotton holder previously immersed in 
a solution of liq. ferri persulph. This application should be 
made to the leech bite in the most thorough manner. Pressure 
on the leech bite by the finger will also often arrest the haem- 
orrhage. If both of these fail, use a solution of arg. nit, grs. 
xx. to xl. to the ounce of water, in the same manner as the 
styptic iron was applied. When the leech fails to relieve the 
pain we may resort to large doses of morphine administered 
hypodermically. Under the circumstances the remedy is likely 
to act satisfactorily, and indeed morphine has nearly as much 
power in relieving inflammation of the ear as it has in peritoni- 
tis, for which it has such a reputation. Next in value to the 
leech is the application of heat or warmth to the ear. As a 
rule dry warmth maybe selected instead of moist, as the latter 
produces a macerating effect on the canal, which encourages 
otorrhcea and the formation of polypi. There is this exception, 
however : if the moist warmth is only continued for a short 
time and the part well dried, afterwards there is little danger, 
and the moisture of the warmth does facilitate the unloading of 
blood-vessels. My experience, however, is on the whole favor- 



234 DISEASES OF THE EAR. 

able to dry warmth. A rubber bag filled with hot water is the 
most elegant and convenient method of applying warmth. The 
temperature of the water may be carefully adjusted to that 
degree which contributes most to the comfort of the patient. 
This detail is quite an art. I remember a patient who had a 
severe pain in the whole side of the head from an otitis, which 
was aggravated by either very hot or moderately warm water ; 
by adjusting the temperature to a middle point the pain was 
relieved. Very rarely cold applications do good, but, as a rule, 
cold is banished from the therapeusis of aural surgery. 

Common salt heated and placed in a bag and laid on the 
ear is a good remedy; a bottle of hot water may be used for 
the same purpose, but instead of laying it on the ear, the latter 
should be laid against the bottle, as its weight would be pain- 
ful to the sensitive ear. No objection need really be made to 
a flaxseed poultice, especially as laudanum or some other ano- 
dyne may be poured upon it, if it is not kept on too long, and 
allowed to unduly soften the parts. Excessive poulticing will 
however cause a dull, aching pain in the ear. I remember a pa- 
tient who, for a considerable time, poulticed an ear which not- 
withstanding continued to be painful; the poultice was ordered 
to be discontinued, and the pain subsided without other treat- 
ment. A roasted onion with the outer part stripped off and 
applied by its conical portion to the meatus is a good domestic 
remedy. Corn-meal, heated and placed in a bag as directed 
for the salt, is also useful. Escaping steam falling on the 
meatus as hot as can be borne is a valuable remedy. The ear 
needs to be stopped with cotton after these applications, to 
prevent taking cold. Remedies dropped into the ear are often 
worthy of recommendation. Magendie's Solution of Morphine 
may be dropped into the ear ; repeat every half-hour to an 
hour until relieved. If the drum cavity is exposed, opium 
poisoning might result from using this too frequently. Dr. 
Theobald of Baltimore (Amer. Jour. Otol. 1879, No. 3) recom- 
mends the instillation of a solution of Atrop. Sulph. gr. iv. to 
the ounce of water. He directs that ten drops be placed in 
the ear and remain ten minutes, then allowed to run out. This 
to be repeated every half-hour until relief is obtained. In one 
case, that of a child, with a ruptured membrane, the pupils be- 
came dilated after the atropine instillation, but he considers 
the remedy safe. We have very little experience with it, and 
do not, as a rule, use anodynes in the meatus. It certainly 
would be proper to carefully observe the effects of the bella- 
donna upon the general system. In a severe case, all these 



TREATMENT OF ACUTE PURULENT OTITIS. 235 

remedies are ineffective. I remember having myself a severe 
otitis where the pain was relieved for three or four minutes 
only by inhalation of chloroform, when after the application 
of a single leech to the tragus, the pain was completely re- 
lieved in less than half an hour. Another remedy that may be 
classed as warmth is douching the ear with Clark's Ear Douche 
(see Page 112). The stream of quite warm water (somewhat 
warmer than is agreeable to the hand)" may be allowed to fall 
very gently on the membrane for from ten to twenty minutes at 
a time. It is most highly thought of by many aural surgeons. 
I do not use it to any great extent, as it occupies consider- 
able time and seems less effective than many other remedies. 
It is, however, convenient in children. 

Another good remedy in the earache of young children or 
infants is a piece of cotton with black pepper in its interior. 
There should be only a small amount of pepper, for fear of 




Fig. 66.— Pomeroy's Modification of the Buttles's Inhaler. 

causing intense burning pain. If the remedy is first tested in 
the ear of an adult, and only a warm sensation results, it will 
be quite proper to use it on the young child or infant. Chloro- 
form vapor, blown into the ear by the Buttles's inhaler, which 
has been adapted for this purpose by Dr. Roosa, of N. Y., and 
also by myself, in a glass instrument (Fig. 66), will sometimes 
prove very soothing to the painful ear. A four per cent, solu- 
tion of cocaine may be poured into the meatus, which should 
afterwards be plugged with cotton-wool. This does not always 
relieve. When the drum cavity is fitted with products of inflam- 
mation, the indications undoubtedly are to puncture or incise the 
membrane, and evacuate its contents. 

The indications of the presence of fluid in the tympanum 
have already been given under the head of ''appearances on 
inspection." My own practice is to use what ophthalmic sur- 
geons call a broad needle, with a tolerably long shank, and 
'puncture rather than make an incision. It will hardly be cred- 
ited, that in passing a needle into the membrane there is some 
risk of pricking the external meatus, but it is quite possible, 



236 DISEASES OF THE EAR. 

as the canal is one and one-fourth inches long, is narrow and 
not quite straight. To obviate this I am in the habit of pass- 
ing the needle down as near to the membrane as possible, 
meanwhile using the forehead mirror and carefully inspecting 
every step, and when the apex of the bulging membrane is 
carefully brought to view, give a quick light thrust until the 
point seems to touch a firm bottom, the inner bony w T all of the 
tympanum. In this step of the operation, the sense of touch 
is more important than that of sight. It is quite necessary for 
the surgeon to feel that the instrument has gone through a 
thin elastic membrane and touched a hard substance beyond. 
If the surgeon is confident of his power to manipulate skil- 
fully, he may incise instead of puncture, making an opening 
in the membrane of about one eighth of an inch in length. 
This generally will be in the posterior and superior quadrant 
of the membrane. The operation may be done with a narrow 
curved bistoury, with either a straight handle or one placed at 
an angle with the blade. Gruber's curved knife (see Index) is 
a good instrument for this purpose. It is not impertinent to 
remark here, that the operation done with an instrument in 
which the handle is placed at nearly a right angle to the blade 
is very difficult of performance. If the surgeon ever feels 
awkwardly it is when operating with one of these instru- 
ments. I know of no stop needle which does well in this op- 
eration ; it is impossible to make it sufficiently delicate to 
penetrate with the requisite facility ; neither is it necessary, as 
too little force is used in the operation to do harm even if the 
inner wall of the tympanum is gently pricked. After the 
membrane is punctured, it will generally be necessary to inflate 
the tympanum by Valsalva's or Politzer's method in order to 
blow the fluid out of the tympanum. If the Eustachian tube 
is impervious, then use a rubber tube to the meatus, exhaust- 
ing the air by the application of a syringe or rubber air bag. 
If Siegle's otoscope be used, the process may be inspected. 
Where the pus is removed by inflation this should be repeated 
until the perforation whistle is elicited, the patient's head be- 
ing so placed that the perforation will be the most dependent 
point; consequently all the fluid is removed before air makes 
its appearance. This operation may be repeated as often as 
the incision heals, provided there is fluid to evacuate. If the 
ear is frequently inflated, however, this is less likely to become 
necessary. 

After evacuating the tympanum it will be interesting to 
note the improved hearing and also the bettered bone conduc- 



PARACENTESIS OF THE MEMBRANA. 237 

tion. Paracentesis or incision of the membrane may be done 
usually without ether, even in children ; but as the latter are 
etherized in from one to five minutes, the anaesthesia becomes 
a small matter. If an adult is peculiarly sensitive, the opera- 
tion may be performed with a Graefe's cataract knife, which, 
when done with gentleness, hardly causes pain. The patient 
had better not be placed against any unyielding object during 
the operation, for the head may be jerked towards the opera- 
tor and mischief might result. It is well to hold the needle so 
gently in the grasp, that if its point unexpectedly strikes 
against an obstacle it will slip in the grasp before being pushed 
violently forward to the infliction of possible injury. 

The febrile symptoms require treatment at times, though not 
always. If the fever runs high it may be well to give the pa- 
tient a brisk purge — a large dose of calomel is excellent — and 
possibly a few small doses of Tr. Aconit. Rad. to diminish 
temperature and pulse ; occasionally where there are head 
symptoms, the bromide of potass, may be given in from ten to 
thirty grain doses every two hours until relief is obtained. 
Occasionally the potass, iodid. in large doses is indicated, es- 
pecially in the latter stages of the disease, when it may be sus- 
pected that the brain may be involved. With the same view 
of diminishing cerebral hyperemia the fluid ext. of ergot may 
be given : 20 drops four or five times daily in a little water. 

After the acute symptoms have somewhat subsided it would be 
well to use an astringent to diminish the discharge if it is not 
inclined to cease spontaneously. The plumbi acet. gr. ij. to 
v. to the ounce of water may be instilled twice a day, the ear 
previously having been syringed with warm water and care- 
fully cleansed with cotton. The acid, carbol. 3 i. to the pint 
of water makes a harmless and cleansing wash which assists in 
keeping the ear free from any unpleasant odors. 

Before using too many astringents in the ear, observe care- 
fully whether it does not incline to recover without much 
treatment, as there is always a natural tendency for the mem- 
brane to heal and the discharge to cease of itself. Indeed, 
we shall find hereafter, that it is nearly impossible to prevent 
the membrane from healing, when we sometimes desire to do 
so. 

A great variety of astringents may be used in this connec- 
tion if it be found necessary ; for arresting the discharge, arg. 
nit. perhaps stands at the head of these remedies. It may be 
used in strength of from 2 grs. to 80 grs. to the ounce of water, 
dropped into the ear and allowed to remain a few minutes. 



238 DISEASES OF THE EAR. 

Sulph zinc. gr. ij. to the ounce of water is useful. Tannin 
with glycerine 3 i, to the 1 i. is valuable. In this connection 
remedies may be selected somewhat as in conjunctivitis. We 
should retain the one we have the best results from, but not con- 
tinue a single agent too long at a time. Boric acid sometimes 
does wonderfully well after the more active symptoms have sub- 
sided ; the canal is to be packed full of the finely-powdered acid. 
If the discharge is excessive I have not succeeded well with the 
boric acid. This should be renewed as soon as the discharge 
moistens it and finds its way out of the ear. Previous to each 
application to the ear the patient should be Politzerized, the 
discharge blown out of the Eustachian tube and tympanum, 
and then removed by syringing with warm water, followed by 
gentle wiping out with the cotton. If the membrane shows a 
reluctance to heal, or the edges of the perforation begin to 
grow granular, the part may be touched with a saturated sol. of 
sulph. cup. or with a xl. or lx. gr. solution of argent, nit. A 
slough should not be produced. The absorbent cotton maybe 
kept in the meatus until the patient is convalescent ; remove it 
whenever it becomes in the least moistened. A very small bit 
loosely applied is sufficient, and does not perceptibly di- 
minish the hearing power. All mastoid ox cerebral complications 
will be considered under their headings as a separate matter. 

Constitutional Managetnent. — As a rule the patient inclines 
to become much depressed by this disease ; demoralized would 
perhaps be a better word. The pain often undergone is suf- 
ficient to profoundly interfere with nutrition, and the patient 
will have the appearance of having been seriously ill for a long 
time ; the face will have a haggard look, the features will be 
shrunken, there may be no appetite, and digestion will be in- 
terfered with. The bowels may be sluggish and the liver 
inactive. One important matter is to see that the patient has 
made up what sleep may have been lost by his severe suffer- 
ings. General attention should be given to his secretions, so 
that he may again be prepared to digest food. Tonics and 
stimulants almost always will be indicated, and his diet must 
be very carefully attended to. The most nourishing food that 
can be digested should be selected. As soon as possible he 
should resume as far as may be his usual avocations. Going 
out and breathing fresh air, with change of scene, will often do 
more for the appetite and digestion than medicines. His 
courage and hope may also spring up anew. As far as possible 
endeavor to prevent the mischievous effects of cold. Relapses 
frequently result in consequence of injudicious exposure. The 



CHRONIC PURULENT INFLAMMATION. 239 

dress requires to be regulated to the production of just suffi- 
cient warmth, but perspiration should be avoided. 

CHRONIC PURULENT INFLAMMATION OF THE TYMPANUM. 

A certain proportion of cases of acute purulent inflam- 
mation of the tympanum fail to recover at the termination 
of the period of active hyperaemia, and the inflammation 
degenerates into a state of more or less passive engorgement 
of the vessels, and we then have the disease under con- 
sideration, viz., chronic purulent inflammation of the tympa- 
num. This results from the acute disease not being always 
self-limiting, or very likely treatment has been neglected 
or unskilfully applied. The reparative action may still be 
going on, but so tardily as not to accomplish a cure within 
the limits assigned to the acute disease, but may, how- 
ever, subsequently terminate favorably. 

Some constitutional conditions may interrupt the prog- 
ress of the disease towards recovery, as struma, tuber- 
culosis, syphilis, Bright's disease, or even a state of general 
debility. In a few instances the disease seems to com- 
mence as a chronic affection. Many tuberculous subjects 
may be found with a discharge from the tympanum with- 
out apparently having had any previous acute symptoms. 
I have seen many cases of chronic otorrhcea, where the 
patient would stoutly maintain that there had been no 
pain nor even uncomfortable sensation in the ear previous 
to the advent of the discharge. The membrana must 
have been ruptured, except in rare instances, and the per- 
foration been of considerable size, or it would have 
healed before this period. There is always a discharge, of 
greatly varying products, but usually it is of the charac- 
teristic purulent quality. As a rule, the discharge con- 
tinues until the membrane is healed. The mucous lining 
of the tympanum is always swollen, being much thicker 
than normal. Frequently it is pale and has lost most of 
its original characteristics. The general tendency of the dis- 
ease is towards the destruction of tissue. The membrane 
may slowly be wasted away by ulcerative processes until 
not a vestige of it remains. The ossicles frequently have 
their ligaments destroyed by the erosive action of ulcer- 
ation and become detached from each other, and may even 
fall out of the ear. The stapes, however, is much less liable 
to be separated from its position in the oval window. 



2-0 DISEASES CF THE EAE. 

Ass: dated vrith the faulty repair atteadcat ~n the :n- 
f- aaaaaatcry ::: tess v.ae have the s: -.aell-ka: ~aa = ad frea dec 
aural rclyai :r guaaulaticas. vucich aaay recur frecycieacly 
after having been removed, e specially if there be un- 
covered :r dead i :.r.e ia their viciaicy. I: is f : : at this dis- 
ease that chronic mastoid affections result. Destruction 
■:: the h. : ay tva ii :: the tyaaraaum aad adjaceac cssecus 
rissaes deread uy:a suppurative :;i:is. aad -,-laea the furs 
~-:e: is ia ccacacc v.vth the diseised h:ae. aueaiagatis. 
cerecral ahscess. thrcaahcsis aad : dliteratisa ■:: siauses 
ad; = ceac t: the ear result: sertuaeaaic^ aad pyaraaia als : 
cccur, Fatal it teua err la a eves have heea : h serve d :r: at the 
extersica ::" these destructive rrcessesc: large arte: 
accahly that :: the eartcid ia its :aaah passiara s: aear :: 
the tyrapcvtuaa. Paralysis fre eye eacly is seer, ceasricacusly 
that :: tite facialis, as it is eftea rrtteeced ia us Fell: 
caaal :y a very thia septuua :fh:ae. :r seraeciaaes evea hy 
a aaeaacraae :a.y. treat tae tyaaaaaura. _ ae aeariaer raay 
he iatpaired frira a very slight degree t: that cfaestluce 
declares Tiaaitas auriuua is aauth less likely t: cccur 
thaa ia raaay ether ear a±'e:ti:as Cacadricis cat reri- 
chtadritis :f the aaeatus aad auritle raay result frzaa this 
aisease :y eateasiia :f iaaaaaraatiza frzaa the druac cavity 
The eateraal teach zftea is ulcerated ia ccaseeueaee ::' the 
::':. a c discharge frcra the y act cat at cat tier grieves 
are excoriated along its itcerior wall. The discharge is a 
prolific save : : eczematc a s affections of the auricle and 
meatus. It has recently been found surcharged with cocco 
bacterise carrying mischief in its wake. So much is this 
disease dreaded, that life insurance companies refuse to 
insure a patient having a chronic otorrhcea. 

It is scarcely possible to anticipate all of the results ac- 
cruing from suppurative otitis. In the Tr. of the Amer. 
OtoL Soc. for 1874, p. 539, Dr. Arthur Mathewson, of 
Brooklyn, reports a case where the destructive processes 
resulted in an opening by a narrow sinus extending from 
the tympanum to the outer side of the tonsil through the 
anterior palatine arch. On pressing the finger against the 
mouth cf the sinus, pus was forced in large quantities into 
the aaeatus. through an opening appar eatly situated a the 
Lower wall of the meatus close to the membrana tympanL 
Tnis could not be followed by a probe. On widely opening 
the mouth, pus was forced into the meatus; pressure on the 
aeck heliv tae aaastcid els: caused 1. discharge at:: the 



CHRONIC PURULENT INFLAMMATION. 241 

meatus. He concluded that there was a burrowing abscess 
deep among the tissues of the neck; no fluctuation. On 
July 1st, an incision was carried downwards, from the pos- 
terior part of the mastoid, as deeply as was deemed prudent; 
no pus was found; this was kept open; care was taken 
with the drainage and medication. These means being 
unsuccessful, trephining was done; only a few cells were 
found and no pus; some hypertrophy. This gave only 
partial relief to pain; subsequently this became excessive, 
requiring morphine. The discharge from the ear and from 
the sinus in the throat again became abundant. Pain extend- 
ing downward along the spine was apparently relieved by 
counter-irritation. In January, the discharge from the ear 
and throat suddenly ceased, and the patient rapidly re- 
covered. Another characteristic of this affection is that 
acute exacerbations are liable to occur which may inflict 
great injury; mastoid affections as well as fatal brain com- 
plications are often traceable to these exacerbations. 

The discharge is the characteristic symptom. It varies 
in quantity from the smallest possible amount, just smear- 
ing over the membrane or tympanic cavity, to an amount 
so excessive that the ear may need to be cleaned every hour 
or two. In the latter instance the external canal may con- 
tribute to the augmentation of the discharge. It is greater 
in recent cases than in those of longer standing. It will 
usually be greater during an acute exacerbation, although 
occasionally it may be less. 

Children usually present a greater amount of discharge 
than adults. 

Its character is predominantly purulent, and of a yellowish 
or greenish color, and it readily mixes with water. In some 
cases mucus may be observed; this does not dissolve in 
water, but appears as grayish ropy streaks. A serous 
character is often noticed when the discharge may be 
transparent or somewhat chocolate colored. When the 
discharge is mixed with flakes of epidermis or epithelium, 
it assumes a turbid, whitish or rice-water appearance. 
Frequently there is a tinge of blood in the discharge. 
This ordinarily indicates the presence of granulations or 
polypi. There is sometimes a thick cheesy-looking ma- 
terial, which may be an admixture of tuberculous matter 
with epidermis and other debris. 

The off ensivexess of the discharge is due mainly to decom- 
position. Pus, mucus, serum and blood have very little 



242 DISEASES OF THE EAR. 

smell of themselves, and if the discharge is removed often, 
there is an absence of any special offensiveness; but let de- 
composition take place, and a great variety of most offen- 
sive odors ensue. The discharge from carious bone is an 
example of the effects of decomposition upon the odor. As 
a further consequence of the decomposition of the discharge, 
B. Loewenberg, in the Archives of Otology for September, 1881, 
speaks of the production of micrococci in very great num- 
bers. Few, however, were present when the proper clean- 
liness had been practised. The microphytes formed con- 
centrical gelatinous envelopes about every minute particle 
of decomposed matter; these were composed of the spher- 
ical bacteria, together with a few of the rod bacteria. 

Appearances on inspection. — The meatus presents a great 
variety of appearances. If the discharge moistens the 
canal, there will be signs of macerated and detached 
epidermis. This will present a whitish or grayish color, 
caused by the presence of numerous loosened epidermic 
scales, which prevent exact inspection of the parts. The 
macerated epidermis often has a wrinkled appearance. 
When it is stripped off, the meatus, especially near its 
tympanal extremity, may be considerably reddened, and 
present somewhat the appearance of mucous membrane. 
In some instances the canal will be much wider than nor- 
mal, as though there had been atrophy of its soft parts. 
In others, and especially in children, the canal will become 
so much infiltrated, that it may be entirely closed. At the 
New York Foundling Asylum this is a very common oc- 
currence. Associated with the macerated and excoriated 
condition of the canal, will be found, in some instances, an 
auricle swollen, red and possibly moist from eczema, the 
consequence of this condition. Grooves are often channelled 
in the lower wall of the meatus, the consequence of the 
ichorous discharge, which often presents a red and bleed- 
ing appearance. When the discharge is less than usual, it 
forms, by evaporation, scabs and crusts which obstruct the 
canal. Impacted cerumen is sometimes seen. Perfectly 
hard swellings of the exostoses are sometimes observed. Aural 
polypi are infrequently seen in the canal, their attachment 
usually being in the drum cavity. 

The membrana tympani is either perforated or has been 
perforated at some previous time. If mostly intact, and 
covered with discharge, the signs of maceration described 
as characteristic in the meatus will be seen in this instance, 



SYMPTOMS OF PURULENT CATARRH. 243 

gray where the dermoid layer is still adherent, and reddish 
where it has been removed. There is almost always a 
higher degree of redness about the short process and 
malleus handle than elsewhere. The folds of the mem- 
brane are not important as diagnostics in this as in other 
conditions. The malleus handle is almost always retracted 
and foreshortened, and does not present the normal in- 
clination, it being in some instances too vertical, and in 
others too horizontal. When the membrane has become 
much thickened and opaque, the site of the manubrium 
may be obliterated, but its location may often be determined 
by a minute red streak showing the manubrial plexus of 
blood-vessels which are upon and on either side of it. 
The perforation in the membrane is more frequently seen in 
its inferior portion, and may be from the size of a pin-hole 
to the destruction of its entire area. As a rule the manu- 




Fig. 67. — A double perforation, one in front of the malleus handle and the other behind, 
a cicatricial new formation being interposed between the perforations. M. M. Manu- 
brium; S. P., short process; A. F., anterior fold; N. A., necrotic point on inner 
wall of tympanum; A. W. anterior wall; P., perforation; D. H., cicatricial band at- 
tached to the end of manubrium; P., perforation; P. W., posterior wall; P. F., pos- 
terior fold. 

brium is in position, and it seems to protect the membrane 
in its vicinity from destruction. A large sized perforation 
may leave a sickle shaped rim in the lower part of the 
membrane, extending upward on either side of the ma- 
nubrium, forming a kidney shaped opening, having the 
malleus handle projecting into its hilus. Again, there may 
be two smaller perforations, one in front of the handle and 
the other behind, or there may be a third perforation in 
Shrapnell's membrane, or in the region of Troltsch's 
pocket. I have with considerable frequency seen a bridge 
of membrane extending downward, somewhat in the direc- 
sion of the malleus handle, fairly dividing a large perfora- 
tion into two unequal parts (Fig. 67). If the perforation 



244 DISEASES OF THE EAR. 

is of large size, and the edges of the membrane are much 
sunken, so as nearly or quite to touch the promontory, the 
exact coloring of the lining of the tympanum may appear. 
Sometimes it is very pale, and again it may be deep red. 
This may give the usual moist reflex, or in some cases 
where the mucous lining of the promontory has become 
nearly or quite dry from the conversion of its epithelium 
into a surface very analogous to that of the skin, it will be 
red, but may have a dry shining appearance. Where the 
perforation is small, and the membrane is not much sunk- 
en, the tympanum will be badly illuminated, and the per- 
foration will appear like a minute dark spot. Sometimes 
the perforation will be only a fissure which may not be 
distinctly or even at all visible. To diagnosticate a perfor- 
ation is sometimes difficult. Where the membrane is en- 
tirely swept away, it is not always easy to determine 
this fact. By touching the part with a probe, the absence 
of the elasticity felt when the membrane is touched will 
usually settle the doubt, but sometimes the membrane may 
be red, and moist, and in contact with the inner wall, when 
by using atmospheric traction with Siegle's otoscope, any 
remnant of membrane may be seen to move. [Recently, in 
1885, 1 diagnosticated total absence of the membrana, when my 
attention was called to the fact that the red surface simulating 
the inner wall of the tympanum moved under inflation. This 
indicated that the membrane was intact.] The perforation 
whistle, elicited by inflating the drum cavity, often settles a 
doubt. If the tympanum contains fluid and air, an air bubble 
may appear opposite the aperture during inflation. If the cavity 
is well filled with secretion it may be seen slowly to ooze out 
of the aperture during inflation, and not until it is emptied will 
the perforation whistle be elicited. If, after cleaning the mem- 
brane with cotton, discharge makes its appearance in a few 
minutes, it probably comes from the tympanum, through an 
aperture in the membrane ; or if, after cleaning the ear prop- 
erly, a small very bright light reflex makes its appearance, it will 
depend upon a reflection from a fluid which is oozing through 
a minute perforation, and which the cotton could not thoroughly 
remove. It is extremely unsafe to give an opinion as to the 
appearance of an ear before thoroughly cleaning. Numerous 
light reflexes may depend on the presence of a fluid. The 
color of muco-pus when rather thick and resting on the mem- 
brane, may give the impression that the latter is the object in- 
spected, and not the muco-pus covering it. I have seen many 



SIGNS OF PERFORATION OF THE MEMBRANA. 245 

grave mistakes in diagnosis made by not first cleansing the ear 
carefully. When there is a point of pulsation in the membrane 
there is usually a perforation. A blood-vessel of considerable 
size is probably well-nigh uncovered by the destructive process, 
and exhibits its normal pulsations. Other explanations are given. 
Its chief interest, however, centres in its diagnostic value. The 
ossicula may often be visible where the membrana has been 
partially or wholly destroyed. Sometimes the malleus handle 
is so drawn inward and possibly imbedded in the swollen lining 
of the promontory as to be invisible, but the short process is 
almost always to be seen. The long shank of the incus may 
frequently be observed passing behind the manubrium and par- 
allel with it, terminating a little more than half-way toward the 
end of the malleus handle. The posterior shank of the incus or 
processus brevis passes backward and somewhat upward and is 




Fig. 68.— Results of suppurative inflammation of the drum cavity. A cicatricial mem- 
brane replaces the normal membrane, which is adherent to the promontory. The 
remains of the old membrane appear sickle-shaped. Ossicles are in situ except the 
manubrium. /., incus; M., malleus; P. W. y post wall; M. T., remains of old mem- 
brane; /. IV., internal wall; A. W., anterior wall. Tansley's case. 

being placed above the field of vision. The ramus of the 
stapes may sometimes be seen opposite the end of the long 
shank of the incus, but somewhat higher up and much 
foreshortened. The round window is not visible, being 
too far towards the posterior inferior quadrant of the tym- 
panum. Its anterior edge may sometimes be seen, however. 
In the absence of the malleus and incus, the head of the 
stapes may occasionally be seen in the superior and pos- 
terior part of the tympanum, as a minute nodule, usually 
reddish, and covered by swollen membrane. When the 
perforation heals, the membrana may assume a tolerably 
normal position and appearance, the substitution mern- 
brane (Valk) may be possessed of all the characteristics of 1 
the normal membrane, but it is more likely to be composed 
of cicatricial tissue, without any division into distinct lay- 
ers; thinner and more yielding than the normal, as is shown 



246 DISEASES OF THE EAR. 

during inflation or by the use of Siegle's speculum. If the 
perforation be large, the repair is accomplished in this man- 
ner : the edges of the perforation become attached to the 
promontory, reparative material is thrown out, filling the aper- 
ture and causing still further adhesions of the membrane to 
the inner waU of the drum cavity (Fig. 68). If the perfora- 




, 



P w. 



Fig. 69. — Represents an old case of necrosis of the superior wall of the osseus meatus 
near the membrana. The latter is perforated. This necrotic point extends upward 
and backward, so as to involve the tympanum, being separated from the meninges 
by a very thin lamella of bone. A probe could not be satisfactorily passed into the 
tympanum, and no perforation whistle could be elicited. No operation for the re- 
moval of dead bone was thought justifiable. There was a slight purulent discharge. 
The canal was so hypertrophied that only a small portion of the membrana was visi- 
ble. P., perforation; 6". P., short process; A. F, 'anterior fold; A. W.^ anterior wall; 
F. C, floor of the canal; M. T., membrana tympani; P. W., posterior wall. The 
membrana was much thickened. Tansley's case. 



(Fig. 69). Occasionally the edges of the perforation come 
in contact with the ossicula, and form adhesions with them, 
instead of with the promontory (Fig. 70). In the repair of 
the membrane, the process may be observed step by step. 
I have seen fibjes shoot across a perforation, gradually 




Fig. 70.— Shows the results of suppurative otitis. P., perforation; M. M., manubrium- 
.S". P., short process; M. 7., membrana tympani; A. F, anterior fold; /, incus; P 
F., posterior fold. Tansley's case. 

tion has extended so as to involve most of the membrane 
in a given meridian, the cavity of the tympanum may be 
divided into two chambers ; and if only one of these com- 
municates with the Eustachian tube, that only can be inflated 



HEALING OF PERFORATE MEMBRANE. 247 

closing it in, and, evidently, from their radiate appearance 
entering into the formation of the fibrous layer of the 
membrane. Great care should be practised not to break 
up these incipient formations, for at first the material is ex- 
ceedingly soft, and is easily ruptured by rough manipula- 
tion. These reparative processes have also been repeatedly 
observed by others. It is well to be always on the lookout 
for any redness, swelling or fistulous openings, on the pos- 
terior wall of the meatus, near the membrana, for here is 
frequently found a communication with the mastoid cells, 
which lie directly in contact with this portion, and which 
may be the source of the persistent discharge. In any 
prolonged and unexplained discharge, it is well to look 
over every part of the middle ear as far as possible, to find 
any minute polyp, or granulation, which might give rise to 
the trouble. About the entrance to the mastoid antrum, 
as Dr. Buck has carefully pointed out, are often found 
polypi or granulations which keep up irritation and dis- 
charge. 

In the treatment of purulent otitis, the first consideration 
is absolute cleanliness. The discharge must all be removed 
in a gentle but effective manner, and as often as it accumu- 
lates in any considerable quantities. Syringing with tepid 
water containing a little salt or carbolic acid or castile 
soap, is the proper procedure to begin with. I am aware 
that latterly many aural surgeons of undoubted ability have 
objected to the syringe. It is true that some patients are 
rendered giddy and faint by having the ear syringed, even 
gently. I once had a patient fall in a faint while I was 
syringing his ear. In a case of suppuration with moderate 
discharge, excessive syringing may irritate so much as to 
increase the discharge. In syringing, all violence should 
be avoided, the patient must not even be rendered un- 
comfortable, and as a rule no harm will result. I use my 
own flange syringe, which is figured elsewhere. For the 
patients' use I order the ordinary one-ounce hard-rubber 
syringe sold in the shops. After syringing, there will be 
some discharge hidden away in various nooks and cor- 
ners, and possibly in the Eustachian tube, which the 
stream of water fails to reach. It will be well to fill the ear 
with warm water, hold the head towards the opposite side, 
then perform Politzer's inflation (Fig. 71). Any matter col- 
lected in the Eustachian tube or its vicinity will be blown 
into the tympanum, and will mix with the water, when it 
16 



248 DISEASES OF THE EAR. 

is easily removed. Some use the Eustachian catheter to 
inject water through the Eustachian tube into the tym- 
panum. Ordinarily this is unnecessary, and may some- 
times be too violent. The same objection obtains to Hin- 
ton's method of fitting the nozzle of the syringe to the 
meatus water tight, and forcing a stream through the 
middle ear and Eustachian tube into the throat. I believe 
this method to be more objectionable than the other, but it 
may sometimes be employed, especially if there is a large 
perforation in the membrane and the Eustachian tube is 
sufficiently pervious. The principal objection to the 
method is, that the column of water may press too 
strongly on the round and oval windows, causing laby- 
rinthine pressure. It is well to always select the simplest 
and least violent methods for cleansing the parts from the 




Fig. 71. — Pomeroy's Apparatus for Performing Politzer's Inflation. 

discharge. An ordinary glass or earthenware bowl maybe 
used in syringing. If very great cleanliness needs to be 
observed, use a second receptacle for the water. The 
practice of Wilde, of using a basin with a strainer in the 
centre, is well enough perhaps for hospital work, but it is 
not altogether cleanly. After all that is possible has been 
done by irrigation, use the absorbent cotton on a holder to 
perfectly dry and cleanse the part. The dentist's cotton 
holder may be used for this purpose. What is really better 
is an ordinary hair-pin straightened. The ends may be 
roughened by rubbing against a file, a piece of stone or a 
brick, so as to enable it to readily "catch" the cotton. 
Before winding on the cotton, dip it into water. The hair- 
pin is superior to other cotton holders: it may be found of 
any convenient size, and being very light, the tactile sensi- 
bility is not at all dulled by its weight. It naturally 
requires a little mechanical dexterity to properly straighten 



MODE OF CLEANSING THE EAR. 249 

it, for no cotton holder works properly if in the least de- 
gree bent. A piece of iridium wire, being very light, 
makes a good cotton holder. The wiping out of the ear 
should be done with the forehead mirror in position, and 
every step of the operation should be carefully observed. 
Where granulations or polypi are present, do not use the 
holder violently enough to cause them to bleed, for this 
will embarrass our operations; or if the membrane is in 
process of healing, care needs to be taken not to break or 
lacerate the newly formed, soft and fragile tissue. Fre- 
quent inflations during this process may be necessary, as 
muco-pus may be blown into the tympanum or through a 
perforated membrane into the meatus and require to be 
removed. Any detached scales or crusts of epidermis, and 
dried discharge or minute particles of cerumen, may be 
gently wiped away by a twirling motion of the cotton 
holder. Avoid causing the parts to bleed if possible. 
Where great gentleness is essential, Clark's aural douche 
may be used, and the cotton swab may possibly be dis- 
pensed with. This careful cleansing of the ear should be 
done by the surgeon himself three to six times a week. In 
the meantime the patient must carry out the instructions 
of the surgeon as carefully as possible. Never syringe the 
ear unless it is necessary. 

In the selection of astringents for the treatment of the lin- 
ing of the tympanum and its contents, and for the arrest 
of the discharge, great care and judgment are necessary. 
We cannot definitely assert which remedy will be the best 
in a given case; this can only be ascertained by thorough 
trial. In the selection of remedies, however, we are to be 
guided by a few cardinal principles, and by the results of 
experience. I will here enumerate the remedies I have found 
most serviceable, and also will give preference for those 
that have stood the test of extended experience in the prac- 
tice of others. I know this has in it an element of empiri- 
cism. I may premise, however, that whatever remedy is 
selected, should be discontinued as soon as it seems to 
have lost its usefulness. 

On the whole, nitrate of silver in solution is one of the 
most effective remedies in the treatment of suppurating 
ears. It has the advantage that it is of service where there 
are granulations or polypi, a point I had noticed at the 
time Schwartzer was, making his studies on the action of 
the nitrate of silver in suppurating ears, but he did not re- 



250 DISEASES OF THE EAR. 

gard the remedy as useful in granulations. There is no 
way of determining the proper strength of the solution ex- 
cept by trial. It may be effective in solutions varying from 
two grains to the ounce of water, to a saturated solution 
(more than 480 grains to the ounce). An average strength 
for children would be from 2 to 20 grains to the ounce, and 
for an adult from 20 to 80 grains. In the JV. Y. Medical 
Journal for December, 1872, p. 631, I reported a case of 
chronic suppuration of the tympanum in an elderly sub- 
ject, with symptoms of tuberculosis, in which there was a 
moderate sized perforation of the membrana with a few 
small granulations. I had treated the patient by dropping 
in solutions of arg. nit., of about the strength of 100 grains 
to the ounce. It never was painful, and it diminished the 
discharge, but did not arrest it. I felt that the remedy was 
a good one, but that its power required to be increased; so 
I dropped in a saturated solution, and watched carefully 
its effects. The ear was syringed out with water in a min- 
ute or two. Beyond a slight feeling of fulness in the ear, 
and a little warmth, there was no pain. From that time on 
there was no more discharge, and six months afterwards 
the membrane was found to be healed. (The patient had 
not returned after the application, until that time.) I have 
used the same solution many times since. It has some- 
times caused pain, but never has there been any consider- 
able reaction. I remember a case of suppuration where 
the aperture in the membrane was so small that intra- 
tympanic injection was impossible, and the discharge per- 
sisted. Two applications of the saturated argent nit. sol. 
to the membrane arrested it, but its use was accompanied 
by a little pain. I never have seen sloughing of the mem- 
brane result. The mode of application is very important. 
My practice is to use a medicine dropper and inject a suf- 
ficient amount to fairly inundate the parts, the head being 
turned so that the meatus is placed pointing upward. 
While in this position inflation may be done to still further 
insinuate the remedy into every part of the tympanum. I 
also frequently, with the pipette inserted into the canal, 
alternately draw out and reinject the remedy again and 
again. A still further effect is obtained bypassing the cot- 
ton wool over the parts, performing a sort of "rubbing in 
process." If there is pain, syringe with warm water. The 
effect is greater, however, if the solution is allowed to re- 
main in the ear, a bit of cotton moistened with salt and 



TREATMENT OF SUPPURATIVE OTITIS. 25 1 

water being applied to the meatus. This may be allowed 
to remain for some hours. Obviously there will be no 
staining of the meatus by the nitrate of silver. There may 
be applications made every second or third day ; as long 
as the effect of the first is still operating, do not repeat. 
Over-treatment is always to be avoided. I am not satisfied to 
recommend nitrate of silver indiscriminately, for it some- 
times does harm. If there is not prompt reaction from its 
effects all the symptoms may be aggravated ; the indica- 
tions will then be to weaken the solution, or abandon the 
remedy altogether. I have seen granulations grow in a 
very vigorous manner, under the irritation of the nitrate, 
and also have seen them rapidly disappear under its influ- 
ence. No remedy requires more careful observation. 
While it is one of the most effective of agents, it is also a 
hazardous one. Boric acid, in very fine powder, as recom- 
mended by Bezold, is a most valuable remedy. It should 
be pulverized by a machine made for the purpose, which is 
used by the wholesale druggist. The ear having been 
properly cleansed and dried, the meatus may be filled with 
the powder, and even packed, by means of the cotton- 
holder or any of the approved powder-blowers. Dr. W. B. 
Johnson, of Paterson, N. J., uses a quill of about the size of 
the meatus, attached to a rubber tube. By plunging it 
into a mass of the acid it is readily filled, when it is in- 
serted into the meatus, and by the pressure of a column of air, 
propelled by the breath, it is readily pushed deeply into the 
meatus. This process may require repetition once or twice 
to completely fill the meatus. The powder does not fly by 
this manoeuvre. Another method is to place in the meatus 
a long, rather narrow speculum, and fill the ear by means 
of an ear spoon, packing it by a bit of cotton on a holder. 
If the discharge is moderate the boric acid may remain 
in several days ; if there is considerable discharge the acid 
will be moistened and dissolved sufficiently to allow free 
exit to the discharge, when it may be syringed out and re- 
newed. Recently I was much gratified to witness the ef- 
fect of this remedy at the Manhattan Eye and Ear Hospital. 
A considerable number of cases of suppuration were not 
doing well under nitrate of silver and other astringents, when 
boric acid was used. To my great delight, in most of 
them the discharge ceased in a few days. It is serviceable 
even in minute granulations, and is a valuable disinfect- 
ant to the decomposing matters always found in a dis- 



252 DISEASES OF THE EAR. 

charging ear. Dr. Loewenberg, of Paris, adds alcohol 
to the boric acid, thinking it more effective in destroying 
the microphytes found in the decomposing discharge. He 
uses the alcohol diluted at first until the patient can bear it 
in full strength. I have not on the whole been favorably 
impressed with the efficacy of the alcohol treatment. Neither 
do I believe that any remedy needs to be used to destroy 
organisms incident to decomposition, provided proper clean- 
liness be practiced. The above comes under the head of " dry 
treatment " so much spoken of at this time (1883). I herewith 
insert a few cases of suppurative otitis treated at the Manhattan 
Eye and Ear Hospital, mostly by boric acid. The report is 
made out by Dr. Hepburn : 

John Glynn, set. 40, applied for treatment September 3, 
1873, having impacted cerumen in his right ear. After the re- 
moval of the cerumen the patient was found to have otitis 
med. supp. chron. with a large perforation of the membrana ; 
no granulations. In March had pain in the ear lasting about 
two months (?), which subsided on the appearance of the dis- 
charge. Treated by boric acid in the usual manner. Septem- 
ber 10th, discharge much diminished ; perforation as before. 
September 24th, discharge ceased, perforation not healed. 

Francis Cuny, set. 13, has suppurative otitis media chron. of 
several years' duration. Boric acid treatment commenced 
November 12, 1883. December 21st, discharge much dimin- 
ished ; same treatment continued. Jan. 11, 1884, condition 
unchanged ; boric acid discontinued, and a twelfth gr. sol. of 
hyd. bichlo. substituted. February 4th, discharge entirely 
ceased ; perforation much diminished in size ; hearing notice- 
ably improved. We have used the bichloride solution some- 
what, latterly, and find it a valuable remedy, being, as is well 
known, a perfect disinfectant. It is sometimes irritating, and 
occasionally produces some constitutional ^effects, but rarely 
when used as weak as this. It was applied twice a day to the 
tympanum by instillation. 

Hattie L. C, set. 19, admitted October 12, 1883. Both 
membranes perforated ; left only discharges ; is very hard of ' 
hearing. Boric acid treatment, with very careful cleansing. 
January n, 1884, discharge ceased; the hearing for noises 
has improved, but not for musical tones. Politzer's inflation 
was practiced, and subsequently a still further improvement to 
the hearing was noted. 

Maggie Fitzgibbons, set. 4, chronic suppurative otitis ; ad- 
mitted November 30, 1883. She had a small perforation in 



TREATMENT OF SUPPURATIVE OTITIS. 253 

the drum membrane. Treated by boric acid. On January nth 
the discharge had ceased and the perforation was healed. 

Cora O'Brien, aet. 16, admitted January 7, 1884 ; otitis 
media supp. chron. Boric acid treatment. January nth, no 
discharge. January 25th, no discharge, but perforation not 
healed. Did not return. 

Sarah Gorman, set. 20, admitted August 24, 1883. Has had 
otitis med. supp. chron. in both ears for several years ; there is 
a small perforation in each membrane. Boric acid treatment. 
September 10th, discharge diminished, but not arrested. The 
ears were then filled with a 40 gr. solution of arg. nit., which 
arrested the discharge for one week, when it returned. Then a 
twelfth of a gr. solution of hyd. bichlor. was used without success. 
January 5th, resumed the boric acid, and by February 9th the 
discharge had disappeared in the left, and nearly so in the right. 

The following summary of cases treated at the Manhattan Eye 
and Ear Hospital, and at the Demilt Dispensary will be found 
interesting, as it bears directly on this subject. It is made up by 
Dr. N. J. Hepburn, assistant-surgeon to the Manhattan Eye and 
Ear Hospital, in my service. The cases were treated, as the 
sequel will show, almost altogether with powdered boric acid 
(the very fine powder made by the wholesale druggist). I have 
observed that in cases approaching the acute or subacute form, 
where there was considerable discharge, that the boric acid was 
of no use whatever unless as a disinfectant. I have not seen 
it remove granulations of any considerable size, and it seems 
to me impossible that it should do so. The powder has been 
packed in the meatus, as has been previously described. It 
has been allowed to remain in until it has become moistened, 
then removed by syringing and reapplied. Sometimes it has 
remained in for ten days, still being dry, and not causing in- 
convenience except in one or two cases, when a little pain was 
experienced. I have seen no trouble arise from a tendency to 
cake in the canal, as has been mentioned (Brandeis). I re- 
gard it as the most satisfactory remedy in chronic suppurative 
otitis that has recently been devised. The cases were treated 
during the eighteen months previous to March 1, 1885. Total 
*— number of cases treated, 130. Of these 43 were treated at the 
Manhattan Eye and Ear Hospital, and 8^ at the Demilt Dis- 
pensary ; of which, in 75, or 6)4 $>, the discharge ceased under 
boracic acid alone ; and in 15, or 12^2 fo, it was necessary to use 
nitrate of silver in solution or fused on a probe to remove granu- 
lations before the discharge would yield to boric acid ; and in 
12, or 10 ft, polypi had to be removed by forceps before boric 



254 DISEASES OF THE EAR. 

acid would arrest the discharge ; in 10, or &}i $, boric acid 
diminished, but did not permanently arrest the discharge ; in 
8, or 6 2 A fo, there was no effect from boric acid. In 4, or 
2> X A i°-> treatment has not been continued long enough to 
report ; 6, or 5 $, did not return after the first examination 
for treatment ; total, 130. The shortest duration of successful 
treatment was six days, in a case where there had been con- 
tinuous dischaige for eighteen years, and in this case the dis- 
charge disappeared in twenty-four hours. The- average dura- 
tion of treatment in successful cases was three weeks, and the 
longest time was three months. 

I am sure that after what I have said about the ill effects 
of the maceration and soaking of the parts by excessive 
syringing and douching of the ear and the avoidance of 
undue moisture in treatment, that no one will accuse 
me of going too far in the direction of moist treatment. 
Dr. H. N. Spencer, of St Louis, has written in the Amer. 
Jour, of Otology, vol. ii. p. 184, on the dry treatment of sup- 
purative otitis. He quotes Becker as authority for the dry 
mode of cleansing the ear, and gives cases illustrative of his 
mode of " dry dressing" for the ear, as follows : — Iodoform 
is blown into the ear so as thoroughly to come in contact 
with the parts; a bit of absorbent cotton is then pressed 
down quite upon the membrana tympani and allowed to 
remain. This dressing with the iodoform in one case was 
renewed twice a day for four days, when the discharge had 
ceased. After that the cotton alone was used. He thinks 
that the cotton by itself will be sufficient treatment in some 
cases; it protects from the air, absorbs moisture, and gently 
stimulates the parts. He is in the habit of applying the 
cotton, then inflating, and the moisture forced through the 
perforation sticks the cotton to the membrane and affords 
an admirable dressing. In an article published by me in 
the N. Y. Med. Jour, some years since I advocated packing 
the tympanum with cotton, but at that time there w r as no 
absorbent cotton, the latter being so superior to that which 
has not been prepared. Dr. S. thinks that the cotton exerts 
traction on the edges of the membrana tympani, bordering 
the perforation and prevents sinking. I have had ex- 
cellent results with iodoform. Its unpleasant smell maybe 
diminished by mixing a little balsam of Peru with it, 
(Mittendorf). Powdered alum, burned or otherwise, is a 
valuable remedy blown into the ear. I have known it to 
shrivel up and disperse small polypi in a few days, w r hile 
in other cases it seems quite ineffective. Some years since 



TREATMENT OF SUPPURATIVE OTITIS. 255 

Dr. Agnew of New York was in the habit of using what 
he denominated "alum mud." A supersaturated solution 
of alum was made, and the resulting sediment was pushed 
into the ear instead of the powder. One important contra- 
indication to the use of alum is the resulting coagulum, 1 
which often acts as a foreign body in the ear and is difficult 
to remove. It is quite proper to give the patient a saturated 
solution to pour into the ear daily, after syringing. Gruber 
objects to using powders in the ear on account of their 
collecting into masses and acting as foreign bodies. He is 
also in favor of seeking out diseased places in the tympanum 
or membrana, and making a stronger application to these 
parts only. I have often done this with arg. nit. 

Some years since the permanganate of potassa was quite 
fashionable, especially as it was a good disinfectant. I used 
it for a time, but it has latterly somewhat fallen into dis- 
use. Recently Dr. Lucien Howe (Tr. Am. Otol. Soc. 1879, 
p. 360) has revived its use, and is very favorably impressed 
with it. He uses a solution of from two to eight grains to 
the ounce of water, instilled once or twice daily; allowing it 
to remain five or ten minutes, or syringing it out sooner if 
it causes any smarting or burning. Whatever agent is used 
may be placed on a cotton pellet and pushed down upon 
the part. Dr. Gruber, of Vienna, passes a small quantity of 
a mild astringent into the posterior pharynx, inclines the 
head to the side of the affected ear, and the agent is blown 
into the tympanum by Valsalva's method of inflation. 
Sulphate of zinc in solutions of from one to six grains to 
the ounce of water is a valuable astringent. It may be used 
in the ear two or three times daily. The chloride of zinc, in 
weaker solutions, may also be used; it resembles somewhat 
the arg. nit., but it is apt to cause pain at times. Troltsch 
recommends solutions of cup. sulph. in from one to five 
grains to the ounce of water where there is carious bone. 
This is one of the most valuable of all the remedies for con- 
junctival diseases, but in the ear it is sometimes rather pain- 
ful, and its intense astringent action seems occasionally to 
produce unpleasant irritation. Plumb, acet., in from two 
to ten grains to the ounce of water, has long borne an ex- 
cellent reputation in otorrhcea. In eye practice it has been 
abandoned on account of its forming insoluble crusts of 
lead upon the cornea, and the same objection to its use has 
been made in ear practice, but I never have observed any- 
thing in its action to cause me to abandon its use. It some- 



256 DISEASES OF THE EAR. 

times does admirably in diminishing the gelatinous softness 
of a mucous polyp previous to its removal. Carbolic acid, 
although a few years since, as a new remedy, was somewhat 
too highly extolled, is really a good agent, even to diminish 
a discharge from the ear. It still holds its place as a good 
antiseptic, and deserves to be used. From two to five 
grains to the ounce of water is a proper strength. Any 
pain it causes quickly subsides. Other remedies to dimin- 
ish the offensive odor from a suppurating ear are the liq. 
sod. chlorinat. about 3j to an ounce of water. The per- 
manganate of potassa is valuable also for this purpose, in 
strength of, from one to three grains to the ounce of water. At 
the New York Foundling Asylum we have had many cases of 
suppurative otitis, in which the meatus was much narrowed 
and in some cases even entirely closed by the swelling of 
the canal, induced by the acrid discharge. Many of these 
cases had swelling also of the auricle from the eczema ac- 
companying this affection. I tried a variety of expedients 
for the relief of this condition. The canal was incised at 
first, and afterwards an extensive incision was made be* 
hind the auricle opposite the meatus, so as to communicate 
with the deeper portion of the latter, which was not usually 
narrowed; this it was hoped would allow free exit to the 
discharge and permit the ear to be cleaned and astringents 
applied. These measures failed. Dr. Chadbourne, of New 
York, then the House Physician of the Asylum, suggested 
and successfully carried out an idea of his own — to use rub- 
ber drainage tubes. His practice was as follows: If the 
canal was not too much narrowed, a piece of black or red 
rubber was forcibly pushed into the bottom of the meatus, 
and then cut off on a level with the concha, so the child 
could not pull the tube out. In other cases, where only an 
ordinary sized probe (say a No. 8 Bowman) could be passed 
in, a rubber tube was drawn over the probe, the end of the 
latter was filed so as to produce four short prongs or teeth, 
on which the opposite end of the tube was caught; then by 
drawing upon the tube it was so attenuated as to be scarcely 
larger than the probe within; in this condition it was passed 
into the canal. When pushed in sufficiently, the end next 
to the surgeon was allowed to spring back into its natural 
shape, when it drew itself into the canal, and most if not 
all of its former calibre was restored. It was then cut off 
and allowed to remain in, from one to several days. With 
even a very small calibre to the rubber tube, the ear could 



TREATMENT OF PURULENT CATARRH. 257 

be properly cleaned by syringing, and even cotton on a 
very small holder could be pushed in for purposes of 
cleansing. After a few days the canal, by the constant press- 
ure of the elastic tubing, increased in size so that a larger 
tube could be inserted, and after a considerable size was 
reached, it was not necessary to do more than simply push 
the piece of tubing in without the aid of the probe. Rarely 
has any irritation been produced, the patients wearing the 
tubes for weeks together. One little patient was sent into 
the country with a tube in the ear. By some oversight 
it was not removed for several months, when, on his return, 
the ear was found dry and healthy, and the tube seemed to 
have grown into the canal. It was easily removed by forceps 
without injury. Besides restoring the calibre of the canal, 
the result of the constant pressure of the dilating rubber 
tubing, the parts are protected from the irritation of the 
discharge, the source of the trouble. Any granulations in 
the canal are likely to be absorbed by this elastic pressure, 
and altogether its action seems to be quite satisfactory. The 
eczema of the auricle usually disappears quickly without 
any other treatment. Granulations in the tympanum may 
require treatment, when the tube is removed for any op- 
erative procedure. Dr. C. often found that a little carbolized 
absorbent cotton resting at the end of the tube, within the 
concha, collected the discharge by absorption, and prevented 
its mischievous effects on the auricle. This was renewed 
often enough to prevent maceration and irritation of the 
parts. The softer variety of tubing only is proper to be 
used. Some varieties of white, stiff and hard American 
tubing should never be used. They act as irritating foreign 
bodies. Sometimes the patient recovers from an otorrhcea 
without treatment. I was called some years since to see 
the wife of a physician who had been suffering for some 
weeks with a suppurating ear, which persisted in discharg- 
ing ; the membrane would not heal, and there was much of 
the time a dull, heavy pain in the ear. It had been syringed, 
douched, and it seemed to be constantly growing worse. The 
epidermis of the meatus was soddened, detached in places, 
and seemed thoroughly soaked. I advised the stopping of 
all treatment for a few days to see how far the symptoms 
depended on the moist applications. The discharge ceased 
in about a week, there was no more pain, and the membrana 
healed promptly. The ear was cleaned with absorbent 
cotton several times daily to keep the discharge from irri- 



258 DISEASES OF THE EAR. 

tating. Politzer's operation was frequently performed, sim- 
ply to more effectually cleanse the ear. I do not infer that 
a very chronic case would have recovered so promptly. This 
would come emphatically under the head of " dry treat- 
ment." The exacerbations which are very likely to occur 
must be treated antiphlogistically, as recommended under 
the head of acute suppuration; astringents and stimulants 
should not be used until the exacerbation has somewhat 
passed off. The Eustachian tube is often obstructed or 
narrowed by inflammatory swelling of its lining membrane, 
and calls for treatment; this is sufficiently detailed under 
the heading of chronic catarrh of the Eustachian tube. A 
very important object of treatment is to heal the mem- 
brana, as the discharge is not likely to be arrested perma- 
nently, with an open tympanum, the atmospheric vicissi- 
tudes being likely to re-excite the disease into activity. Nat- 
urally, when the tympanum is open, we endeavor to protect 
it. This may be done by wearing cotton wool in the ear, 
loosely applied so as not to diminish the hearing; change 
as often as it becomes in the least degree moist. We may 
also use the Yearsley pledget of cotton pressed upon the 
aperture in the membrana tympani, which has again be- 
come somewhat popular. The subject will be referred to 
under the heading of artificial drum membranes. Expos- 
ure to cold must always be avoided. The ear is never in a 
proper state when insufficiently warm. Even when the 
membrane has healed there may only be cicatricial material 
in the new formation, which readily breaks down On the 
first onset of inflammation. In general terms, I would not 
recommend any specific application to the membrane to 
cause it to heal. If the granulations and polypi are care- 
fully removed, and astringents have been judiciously used, 
and the ear kept sedulously clean, there is a strong and nat- 
ural tendency of the membrana tympani to repair. In fact a 
healthy membrane will heal in spite of being punctured, 
incised, and even where portions have been removed. 
There is a class of cases in which there is no tendency to 
the formation of granulations and polypi, where the mem- 
brana tympani looks pale, sodden, and shows little evidence 
of vascular activity. The mucous membrane of the prom- 
ontory is pale, and if much swollen will be so from pas- 
sive serous infiltration, and possibly no treatment whatever 
will induce reparative activity. The patient mayor may not 
be in a good constitutional condition. If the edges of the 



TREATMENT OF PURULENT CATARRH. 259 

perforate membrane are considerably reddened, and espe- 
cially ii there is a little nodular roughness of outline, point- 
ing to the possible production of granulations at some 
future period, it may be admissible to touch them with a 
saturated solution of cup. sulph. or a 40 grain sol. of arg. 
nit. The latter should not be strong enough to destroy any 
tissue, the stimulating effect only being required In tuber- 
culous subjects, there is a form of otitis which seems to be 
chronic from the commencement; there is little or no pain; 
the tendency to destruction of the membrana tympani is so 
great that it is often described as rapidly melting away, in 
spite of all efforts to prevent the destruction. As a rule 
treatment does very little good indeed. It is true that otitis 
in phthisis sometimes does not show these characteristics; 
the case I reported as cured by the saturated arg. nit. was 
not of this kind, but when the peculiar appearances of a 
typical tuberculous case shows itself, there is a dubious out- 
look for the patient. I have seen a few cases only, where 
repair was at all active. Dr. J. O. Green, in the Amer. Jour, 
of Otology for 1881, No. 2, p. 137, details two cases where an 
exception to this rule is recorded. The first patient was a 
man 50 years of age, with empyema and an undoubted 
tuberculous condition of the lungs. In a short space of 
time, as a consequence of purulent otitis media, two thirds 
of the membrana tympani melted away; the mucous covering 
of the promontory was destroyed, and the bone beneath 
was exposed and roughened. Reparation soon commenced, 
the promontory was covered with mucous membrane, the 
discharge ceased and did not return for the number of 
weeks he remained in the hospital. On leaving, the per- 
foration in the membrana tympani showed a decided ten- 
dency to close. The other case was also that of a man 
aged 40, with advanced phthisis. At first there was only a 
small perforation in the membrana tympani, but in three 
weeks the whole of it had melted away. The discharge 
gradually ceased, and the mucous membrane of the prom- 
ontory, which had been congested and swollen, assumed 
a normal appearance, except that it was perfectly dry. He 
was absolutely deaf from labyrinthine complications. He 
lived six months afterwards and had no return of ear trouble. 
The deafness remained as at first. Suppurative disease of 
the tympanum in Bright's disease of the kidneys, as well as 
in diabetes, is likely to run a very tedious course. 



260 DISEASES OF THE EAR. 



AURAL POLYPI, 

In suppurative otitis, as well as in other forms of ear 
disease, which result in loss of substance of the membrana, 
the mucous surface being in a state of ulceration, the effort 
to repair the loss is likely to result in the production of an 
excess of new material, badly organized and unfit for the 
purpose. This assumes the form of granulation tissue, 
granulations and polypi. It will subsequently be seen that 
I hold no view pointing to the peculiar and complex struc- 
ture of any of these neoplasms. They are all of the same 
nature, essentially, except the malignant forms, which are 
to be hardly classed under the heading of polypi. 

The location of polyps is, first, in any portion of the tym- 
panum, being developed from its mucous lining; secondly, 
from the borders of a perforation in the membrana, more 
likely on its mucous surface; thirdly, from any abrasion or 
ulceration in the meatus. The posterior and inner portion 
of the meatus often presents ulcerations and carious spots, 
communicating with the mastoid cells, which are fre- 
quently the site of granulations or polypi. After a furuncle 
has ruptured, the reparative action may be faulty and granu- 
lations or polypi may spring from the unhealed aperture. 
Fourth, the mastoid cells, especially the antrum, are occa- 
sionally the seat of granulations and polypi. Often, where 
a discharge continues unaccountably, a minute granulation 
may be found at the entrance to the mastoid antrum, or 
the mastoid cells may even be entirely broken down, and 
the cavity filled with polypi. Fifth, the Eustachian tube 
near its tympanic orifice occasionally is the seat of minute 
granulations. Any spot of unsound, necrotic or carious 
bone, in any of the locations here described, is likely to 
give rise to polypi. Sometimes the cicatrix, resulting from 
the repair of a membrana tympani, shows a tendency, on 
slight provocation, to take on inflammation, which often re- 
sults in ulceration, and the formation of minute granulations. 
Especially is this the case where the cicatrix is adherent 
to the promontory. I have seen several illustrations of this 
peculiarity. Dr. Buck also mentions this in his book on 
Diseases of the Ear. One of his cases showed a granu- 
lation on a cicatricial portion of the membrana; this moved 
more freely on inflation than the normal portion of the 



AURAL POLYPI. 261 

membrana, which, indeed, is the rule with new formations, 
they being less resisting than the normal membrane. It 
seems to be a well settled principle, that new formations 
possess less vitality and power to resist disease than normal 
tissues. 

The appearance of the polyps. — In general, the polypus is of a 
red or reddish color. Those situated deeply in the canal or in 
the tympanum are of a brighter red than those projecting 
far into the meatus. If extending to a level with the concha, 
they may be of the color of the skin. Where they are con- 
stantly bathed in discharge, the color is not as intense. The 
soft mucous polypus of gelatinous consistency is of a more 
intense red than the fibrous polypus. In children, they are 







Fig. 72.— From Wilde. Showing the Different Forms a Polypus may take. 

of a brighter red than in adults. In tuberculous subjects 
a polyp is likely to be pale. 

Its size is determined, often, by the limited space of the 
meatus or tympanum. 

Rarely do they extend beyond the level of the concha, 
although I have "seen them do so in some instances. There 
seems little tendency in polyps to cause absorption of 
tissue in their neighborhood, so as to give room for greater 
development, as is the case in malignant disease. 

Wilde and Toynbee have figured polypi of many differ- 
ing shapes and physical appearances, which has given rise 
to a rather complicated nomenclature. Such words as 
these appear: " raspberry polypus, or raspberry cellular; 
racemose; peariform," etc., all dependent on the peculiar 
shape and structure of the tumor (Fig. 72). The lobulated 
polypus is very frequently met with, but it has no particular 
significance. One question may be asked concerning a 



262 



DISEASES OF THE EAR. 



polypus — is it hard or soft ? The considerable amount of 
fibrous tissue in the former and the small amount in the 
latter determines the consistency. 

In the Transactions of the Amer. Otol. Soc, 1874, p. 541, 
I described a case where moderately soft polypoid material 
filled the meatus, beneath which was found a material of 
cartilaginous hardness; beyond this was bony material 
occluding the canal. 

The structure of polypi is about as follows: An ordinary 
mucous polypus was removed by me, at the Manhattan 
Eye and Ear Hospital, from an ear which had been sup- 
purating for many years. Several similar polypi had been 




8 vJXi 



Fig. 73. — Microscopic Appearance of a Mucous Polypus of the Tympanum. 

previously removed, all of which were of large size. This 
one filled the meatus, and at its outer portion was of a pale 
red color. The appended drawing is by the Pathologist of 
the Hospital, Dr. T. Mitchell Prudden (Fig. 73). It is done 
in an unusually painstaking and artistic manner; the de- 
scription of the appearance is as follows: 

"The tumor (about one half inch in diameter after hard- 
ening) consists of an abundant gelatinoid, scantily fibril- 
lated basement substance, in which are imbedded numerous 
larger and smaller spheroidal fusiform and branched cells. 
Many of the cells are crowded with pigment; small and 
thin-walled blood-vessels are abundant, especially near the 
surface of the tumor. The whole tumor is covered with 



MICROSCOPIC APPEARANCE OF POLYPI. 263 

lamellated columnar epithelium, which is, in part, ciliated. 
Anatomical Diagnoses — Myxoma Polypoides. 

As the surface of the tumor was covered with small 
folds and indentations, I have represented one of these. 
The epithelial covering is not of uniform thickness over 
the tumor, as is seen in the sketch." 

It is not essential to our purpose to go elaborately into 
the structure of aural polypi. 

So long as they are non-malignant, the indications are 
to remove them. The soft, mucous, or gelatinous variety 
presents in part or whole, the following appearances: they 
all have an epithelial covering, of few or many thicknesses; 
this is either ciliated, columnar, and, in a few instances, is 
of the trabecular variety. Internally the mass is made up of 
gelatinous material called mucin, numerous blood-vessels; 
white and red corpuscles, numerous nucleated round cells, 
a smaller number of spindle-shaped cells, with nuclei; only 
a few connective tissue fibres are present; amorphous gran- 
ular matter is found. The surface of the polypus may be 
rendered uneven by the presence of the papillae. 

A diminution of the fluid contents of the polypus and an 
excess of connective tissue fibres, accompanied by few or 
no papillae, places this in the category of the fibromata. 
The covering of all aural polypi bears a similarity the one 
to the other. Where the polyp is developed in the meatus, 
that is, in a neighborhood containing no proper epithelium, 
the covering of the growth will resemble that of the skin, 
having a coarse flat epithelium, which is sufficiently char- 
acteristic usually to enable a diagnosis of its locality to be 
made. It also true that a polyp of the tympanum if al- 
lowed to extend itself so as to reach the region of the 
concha will be covered by an epithelium of the flat, tes- 
selated variety more nearly resembling that of the skin, 
and in its internal structure there will be less " mucin," 
fewer blood-vessels, spindle-shaped and stellate rather than 
round cells, and considerable increase in the number of 
fibrillae which results in greater hardness than in that found 
in the protected tympanal portion. In a case of suppura- 
tive otitis chronica under the care of Dr. Robt. F. Weir, of 
New York, a polypus was found attached by a long slender 
pedicle to the stump of the hammer. It was removed. 
The case was reported by Dr. A. H. Buck in the Trans. 
Amer. Otol. Society for 1870, p. 75. He calls the tumor 
Angioma Cavernosum, according to the nomenclature of 
IT 



264 DISEASES OF THE EAR. 

Virchow in his treatise on tumors. It is thus described: 
The entire mass . . . consists of blood-vessels, radiating 
from an irregularly shaped central cavity, and separated by 
a network of fibrous connective tissue, holding blood-cor- 
puscles in its meshes. In two or three of the sections a large 
vein can be followed from the central cavity into the remain- 
ing stump of the pedicle. In one of these, and in other 
sections, the point of rupture can be distinctly traced from 
the central cavity to the periphery of the polypus. Six 
weeks after removal a second one made its appearance." 
He quotes Virchow as of the opinion that an angioma is an 
independent new growth of blood-vessels. 

Treatment. — The first indication is to remove the growth. 
This is done by means of the snare, forceps, curette, scis- 
sors, and caustics or astringents. The snare, since the 
days of Sir William Wilde, has been a popular instrument 
for the removal. The best form of this instrument, which 
has been called a modification of Wilde's snare, but which 
really belongs mostly to the inventor, is the one devised 
by Dr. C. J. Blake of Boston (Fig. 74). The cut will 



o* 



G. HEM ANN &C0. 




Fig. 74. — Blake's Polypus Snare. 

sufficiently explain its mechanism. Many other modifi- 
cations are in the market, but this one is quite sufficient 
for all purposes. The instrument may be provided with a 
wire composed of iron or silver. Fishing gimp may also be 
used. If the polypus is of small size a very small wire may be 
used, allowing greater neatness in manipulation and causing 
much less pain to the patient. I prefer fine steel wire; it is 
stronger than the silver, does not stretch as much, and is less 
liable to be cut by sliding through the cylinder attached to the 
instrument. It, however, is liable to rust and become brittle, 
which is not the case when made of silver. The late Mr. 
Hinton, of London, preferred the fishing gimp to any form 
of wire. I have no experience with this, but it seems to 
me to be inferior. In removing a polyp with a snare, the 
principal point is to get the loop completely around the 



MODE OF REMOVING POLYPI. 265 

growth. If it has a distinct pedicle this may not be diffi- 
cult. It will be well to examine the polyp very carefully 
and find where it is attached, whether there are few or 
many points of attachment, or as to the presence or ab- 
sence of a pedicle. To do this, use the forehead mirror and 
speculum, or not, as indications present, and with the cot- 
ton-holder clean the ear perfectly. Then with a probe 
passed around the polyp, a good idea of its location and 
points of attachment may be gained. In fact the probe, or 
cotton-holder without the cotton, is a good instrument for 
diagnosticating the presence of polypi. The next step will 
be to adjust the loop of the snare to the size of the polyp. 
By drawing it closely upon a speculum this may be accom- 
plished. If the polyp springs from the side of the meatus 
or tympanum the loop of the snare may project directly 
out of the instrument, but if it is attached to the mem- 
brana tympani or inner wall of the tympanum, the snare 
may be bent so as to protrude nearly or quite at right an- 
gles to the barrel of the instrument. In enclosing the 
polyp in the snare it may be passed directly down upon the 
tumor without any trouble; but generally it will be neces- 
sary to pass in a probe and push the loop deeper in, so as to 
reach the portion of the polypus near its attachment. 
When the wire is drawn upon, it should be done gently, so 
as not to allow it to slip, and cause the patient too much 
pain. After the tumor is well circumscribed, then use 
traction. My plan is to give a succession of very gentle 
"jerks," so as to break off as much of the tumor as possi- 
ble, not using force enough to extract anything except the 
tumor. By this plan it may be detected if any improper 
object be contained in the snare. Sometimes the latter has 
caught upon the malleus handle in the effort to remove a 
polypus. In a case reported by McBride in the Ed. Med. 
Jour. y Apr. '81, p. 900, the patient having a polypus re- 
moved by the snare, felt as though the loop was caught 
around the tongue. It was believed that the chorda tym- 
pani had been injured by the operation, as there was no 
taste on that side of the tongue for a considerable time 
afterwards; it was, however, recovered. Moss of Heidel- 
berg (Archiv. OtoL, N. Y., 3, '8o, p. 35) removed a polyp by a 
snare, which caused traumatic paralysis of the chorda tym- 
pani nerve, although the latter was not seen during the 
operation. There was numbness of the right half of the 
tongue, with blunted taste, but the sense of touch was inten- 



266 DISEASES OF THE EAR. 

sified. The patient recovered completely in one month. 
Although the snare in general is the best method of re- 
moving polypi, there are the following objections to its use 
in the manner just described. When the tumor has a 
broad base and its violent evulsion is likely to remove 
some of the contents of the tympanum, as the membrana 
or ossicula, or wound the chorda tympani, or do violence 
to either of the fenestra?, it is unsafe to use it, but the 
polyp should be cut off by tightening the loop of the 
snare upon the growth without using traction upon the in- 
strument. Naturally this course makes an incomplete 
operation. 

The Forceps are preferred by me for the removal of 
polypi and granulations, for the following reasons: It is 
capable of removing any kind of polyp, while the snare is 
adapted only to those of considerable size. If there is no 
pedicle the snare does not operate satisfactorily. It is 
more painful usually than the forceps, unless a very fine 
wire is used, when it will be found too weak for a large 
growth. It does not remove the whole of the growth as a 
rule; it is liable to catch other objects than the tumor, and 
its mode of removal is by breaking or cutting off the poly- 
pus, while the forceps, by continuous torsion after being ap- 
plied, will remove a much larger portion of the neoplasm. 
Let the instrument be selected which the individual sur- 
geon can best use. The common small-sized straight nasal 
polypus forceps does very well in ear work, and being 
straight allows of more convenient handling when the tu- 
mor is removed by torsion. 

Hinton's angular forceps with reverse openings (Fig. 
75), so as to operate more conveniently within a speculum, 
is a good instrument, although complicated and expensive. 
Gruber has devised a forceps with reverse openings, quite 
similar to Hinton's, but without the compound jointed 
apparatus, which operates as well, and is much less liable 
to get out of order. The objections to Toynbee's lever ring 
forceps (Fig. 76) is, that the neck of the instrument near the 
catch is so slender as not to allow of any torsion of the 
polypus without twisting the instrument out of shape. A 
most admirable pair of forceps is one devised by Dr. H. D. 
Noyes, of N. Y. (Fig. 77). The lower jaw of the instru- 
ment is fixed, the upper being attached by a pivot, which 
acts as a fulcrum to a lever ; this is moved up and down by 
opening and closing the handles. The leverage of the jaws 



POLYPUS FORCEPS. 



267 



is so judiciously applied as to make it very powerful in 
grasping an object, and it does not obstruct the view like 




Fig. 75. — Hinton's Angular Forceps. 

other forceps. I had a mouse-toothed forceps made forme 
some years since by Stohlman, Pfarre & Co. of N. Y., with a 




Fig. 76.— Toynbee's Lever Ring Forceps (modified by Bumstead). 

reverse opening like Gruber's, which is useful in extracting 
minute granulations (Fig. 78). I am in favor of attach- 




Fig. 77.— Noyes's Polypus Forceps. 



ing what instrument makers call a "magic catch" to poly- 
pus forceps. Two minute hook-like processes are attached 



268 



DISEASES OF THE EAR. 



to the inner surface of each handle, and when the instru- 
ment is closed they interlock, holding it in position. By 
this method the tactile sensibility is left free, and torsion 
may be accomplished in a proper manner. The forceps is 




Fig. 78. — Pomeroy's Polypus Forceps. 



opened again by a slight lateral movement of the handles. 
Dr. Buck, of N. Y., has devised an instrument for scraping 
out granulations and polypi, called a curette. The cut (Fig. 
79) will give a better idea of its construction than a de- 



i .^-s tvosAa, 8t.&&* 



=0 -o 

Fig. 79. — Buck's Curette for Removing Polypi. 

scription. It is quite astonishing how readily granulations 
may be scraped out of the ear by this instrument. Several 
sizes are used, as is seen in the cut. Especially well does 
this operate after a polyp has been cauterized, when the re- 




Fig. 80. — Gruber's Scissors for Removing Polypi. 

suiting coagulation or slough is easily scraped away. [The 
ring of the curette presents a cutting surface.] When 
the polyp is attached by a very tough and fibrous pedicle, 
it is often desirable to remove it by a pair of scissors 
(Fig. 80). Removal by caustics and astringents is sometimes 



TREATMENT OF AURAL POLYPI. 269 

easily done, but in other instances it is impossible. I have 
seen polypi grow with extreme luxuriousness, while bathed 
every second day in a strong solution of arg. nit. Again, the 
same solution may cause dispersion of polypi of long stand- 
ing after a few instillations. A case of my own, reported by 
Dr. D. Webster in the Med. Record, N. Y., Vol. VI., reads, 
" removal of a polypus of ten years' standing, by four 
applications of a 40-grain solution of arg. nit., used by in- 
stillation," and sufficiently illustrates this phase of the ques- 
tion. It was a mucous polyp, but it is not certain that it 
had been in existence as long as the report would indicate. 
This, however, was the duration of the suppuration on 
which the polyp seemed to depend. Sometimes alum, 
burned or otherwise, will shrivel up a polyp very promptly. 
Boric acid, used after the manner of Bezold, and des- 
cribed in detail under the heading of chronic suppurative 
otitis,will sometimes cause dispersion of these growths when 
somewhat minute. Dr. Seely, Trans. Amer. Otol. Soc. y 
187 1, p. 26, uses crystals of chromic acid on polyps, and 
finds them sometimes to disappear after 4 or 5 applications 
are made, at intervals of one week. This is better success, 
I suspect, than others have met with. Some years since I 
used chromic acid, but afterwards abandoned it as it was 
found difficult to confine its action to the polyp. Where 
there is dead bone, the action of cup. sulph. is very satisfac- 
tory. It may be applied in saturated solution, by means of 
the cotton holder, or it may be used in substance. In solu- 
tion it may^rubbed into the granulations more thoroughly 
than when irs-ed in substance; moreover, the method by the 
cotton on the probe is much easier to adjust to the require- 
ments of a given case. Iodoform is sometimes useful. A 
bit of moistened cotton on the holder is thrust into a quan- 
tity of the agent, and then applied in the usual manner 
once in one or two days. An important objection to this 
agent is its unpleasant odor; this may be diminished by 
rubbing it up with balsam of Peru. Nitric acid fort, ap- 
plied by the cotton on a probe or by means of a glass rod 
is very effective in destroying polypi. Nothing but the 
polypus or its pedicle should be touched, as it acts violently 
even on parts protected by the skin. The acid nitrate of 
mercury also may be used in the same manner, remembering 
that it is more violent in its action than even nitric acid, 
and is more likely to cause severe reaction. It is some- 
times more effective than almost any other application. 



270 DISEASES OF THE EAR. 

Dr. Edward H. Clarke, of Boston, recommended the injec- 
tion of 2 or 3 drops of the perchloride or persulphate of 
iron into the substance of the polyp, by means of a hypo- 
dermic syringe. In his book (" Observations on the Nature 
and Treatment of Polypus of the Ear," Boston, 1867) he 
says: " It causes considerable but not intense pain for ten 
or fifteen minutes," and in a given case caused the polyp to 
shrivel up, turn black, and in forty-eight hours dropped 
out of the ear, a black mass. It did not return. This re- 
sulted after a great many other methods of treatment had 
failed. I believe Dr. Hackley, of New York, has also used 
this method. It is a rather harsh mode of treatment; the 
iron is likely to irritate and to blacken the ear, making it 
objectionable. Dr. Clarke also recommended potassa fusa 
on polypi. If the parts surrounding the tumor are packed 
with cotton soaked in acetic acid it is safe to use it, but it 
is violent in its action and difficult of management. Al- 
most any of the astringents used in suppurative otitis may 
act favorably in removing granulations or polypi of small 
size. When the growth is of considerable size, and is 
covered by a thick skin-like epithelium, almost all forms of 
astringent and caustic treatment are likely to fail: or if the 
tumor is fibrous in character this treatment is not likely to 
succeed. The use of astringents and caustics in removing 
these growths requires some hints. It is rare that the 
whole of a growth is disposed of by instrumental means, 
and that which remains must be managed by the method 
under consideration. If a polyp is of the mucous or gelat- 
inous variety it will be difficult to grasp it with any instru- 
ment whatever. If any effective astringent is poured into 
the ear, the growth becomes somewhat coagulated, is more 
friable, having no longer a gelatinous appearance, and may 
readily be removed by instrumental means. This treatment 
also disposes of the haemorrhage, which in some very vascu- 
lar tumors is exceedingly embarrassing. Arg. nit. is the 
best agent for this purpose. A good plan is to saturate 
cotton on a holder with a strong solution (80 to 100 
grains), and rub it into the growth, then remove by snare 
or forceps what is possible; if there is haemorrhage suf- 
ficient to embarrass, clean the ear again by syringing, dry 
it, and reintroduce the arg. nit. By these means most of 
the growth may be removed at a single sitting. I place 
very great stress upon the rubbing-in process. Some (E. 
H. Clarke) recommend using the astringent for several 



THE CAUTERIZATION OF POLYPI. 27 1 

days previous to the removal of the polyp. A good plan 
is to pour in a 40-grain solution of art. nit., pass in the cot- 
ton and move it about among the granulations, then stop 
the ear with cotton (on which salt and water has been placed), 
and allow the arg. nit to remain in the ear from 15 to 30 
minutes, provided there is no pain, then attack the growth 
with instruments. The arg. nit., even in pretty strong solu- 
tions, causes little or no pain to parts covered by skin, 
although the contrary is stated in some of the books. 
The bleeding may be quite profuse at times, but there is 
never any danger. A tampon will always arrest it. Ni- 
trate of silver has in my hands been found to act as well as 
any other haemostatic. Rohland's styptic cotton bears a 
good reputation, but I have seen it fail. A malignant 
growth is more likely to give trouble by excessive haemor- 
rhage. It is of the greatest importance to search carefully 
for minute granulations in the most remote and un- 
suspected parts of the tympanum and its neighborhood, to 
find the true cause of an existing otorrhcea. Dr. Buck, of 
N. Y., has called attention to this matter, which it so well 
deserves. I at one time removed granulations from the mas- 
toid cavity (the cells being broken down by caries) through 
an opening in the external table. There had been a chron- 
ic suppuration of the tympanum, with granulations. The 
amount of polypoid material removed at the first sitting 
under ether was enough to half fill a teaspoon. There was 
considerable haemorrhage. This operation was repeated at 
least four times, at varying intervals, less and less granu- 
lation material being removed at each subsequent sitting. 
There was dead and denuded bone in every direction, but 
the patient, two years afterwards, was entirely convalescent, 
and had a useful amount of hearing, that is, could hear 
ordinary conversation at three feet. The tympanic orifice 
of the Eustachian tube is often the seat of granulations. 
These may be managed by injections through the catheter 
or by injections through the tympanum into the throat, 
after Hinton's method. At the posterior or superior part 
of the canal may often be found granulations, which are in 
reality attached by a pedicle to a point within the mastoid 
cells. These may be reached by thrusting a bent probe 
armed with the cotton, saturated with the caustic, deeply 
into the part, or the aperture may be enlarged by incision. 
Dr. Agnew, of N. Y., has devised an instrument somewhat 
resembling a " bill hook" for incising this part of the canal. 



272 DISEASES OF THE EAR. 

The upper part of the tympanum is a favorite seat for 
polypi. These are difficult of access, as it is above the upper 
border of the meatus. A bent probe with arg. nit. fused on 
the end is a good procedure, or even the cotton on a holder 
sharply bent will serve. A minute syringe with a curved 
point may reach the part by means of injections. Dr. Buck 
has a small glass instrument for doing this work, although 
it is exceedingly fragile. 

The entrance to the mastoid antrum at the upper and 
posterior part of the tympanum is a favorite seat for gran- 
ulations. One or two minute granulations in this region 
are quite sufficient to perpetuate an otorrhcea. When the 
perforation in the membrana is small, and there is un- 
doubted evidence that there are polypi in the tympanum, 
it will be proper to incise the membrane sufficiently to 
allow the growths to be reached and dealt with in the usual 
manner. It is, however, possible in some instances, by 
astringent injections, forced from the meatus inward, after 
the manner of Hinton, to reach the parts and effect a cure. 
Injections through the Eustachian tube by means of the 
catheter will also accomplish the same purpose; or an 
astringent may be thrown into the nostrils, the head being 
turned towards the affected ear, and, by performing Val- 
salva's operation, force it into the tympanum. A similar 
plan also may be adopted after this manner: about half 
fill the meatus with the astringent, turn the head to the 
opposite side, adjust the air bag by means of a nozzle 
tightly fitting to the meatus, then, when the patient per- 
forms the act of deglutition, gently compress the bag, and 
the column of fluid is forced into the tympanum and 
through the Eustachian tube to the throat. It is always 
desirable to adopt the milder methods of application. 

Politzer has introduced the use of alcohol in the treat- 
ment of polypi (Wein. Med. Wochensch., No. 31, 1880). It 
is warmed, and poured into the ear, and allowed to remain 
ten or fifteen minutes; this is done three times a day. If it 
is painful he dilutes with water, but the full strength 
should be reached as quickly as possible. It produces a 
certain coagulating effect on the polyp, and turns it to a 
grayish color. It is more successful in the soft round- 
celled mucous polyp, than in the fibromata. In spongy 
granulations of the middle ear it does exceedingly well. It 
may be used in polypi which are attached to the membrana 
tympani; sometimes he sends the alcohol through the 



TREATMENT OF AURAL POLYPI. 273 

catheter. Dr. McBride, Edin. Med. Jour., Apr., 1881, p. 
900, claims to have used the alcohol treatment before Pol- 
itzer published his results. He finds that sometimes it is 
painful and that it should be used diluted at first. He ex- 
plains that alcohol, from its affinity for water, very readily 
extracts the fluid from the polypi. He also speaks of its 
coagulating effect on the neoplasm. He thinks it causes 
furuncles, from obstruction of the glands of the meatus, as 
is sometimes the case with alum. Alcohol has been used 
quite extensively in New York during the last few years. 
Sometimes it is very successful, and again it appears to be 
absolutely inert. As most remedies at times disappoint our 
expectations, it is well enough to have a large number to 
select from. As far as my experience goes, it is at least a 
very harmless remedy. As to the recurrence of polypi. No 
subject connected with aural surgery will tax our patience 
and courage like the frequency with which polypi return 
after having been removed. Often one would suspect 
malignancy from this peculiarity, yet by a sufficient amount 
of perseverance the growth may be removed so as not to 
return. I have removed a polyp in a given case more than 
a dozen times, with healing of the membrane and perma- 
nent cure as the final result. It is usually stated that when 
these tumors recur so frequently there must be dead bone. 
In the main this is true; but I have seen many cases where 
the polyp had grown frequently and there had been no evi- 
dence of dead or even denuded bone. It is not possible in 
certain cases to determine why a polyp should continue to 
reproduce itself in such a manner. It is generally thought 
that if the base or pedicle of a polyp is thoroughly removed 
by cauterization, electric or otherwise, it is not as likely to 
grow again. Sometimes scraping the point of origin of a 
polypus with a sharp instrument will prevent its recurrence. 
The Consequences Resulting from Granulations and Polypi. — 
Deafness will result if the growth is of considerable size, 
from mechanical obstruction, especially where the meatus 
is completely filled with the growth. If the tympanum is 
crowded with granulations which press upon the ossicles 
and the oval and round windows, hearing will be interfered 
with from failure of the parts to vibrate freely. The tym- 
panum may also be so filled with the growths as to press 
upon the oval and round windows sufficiently to compress 
the labyrinth, and they in turn the terminal filaments of the 
acousticus and interfere with audition. The hyperemia 



274 DISEASES OF THE EAR. 

of the tympanum and meatus, induced by the irritation of 
the growths, and also by the pressure, sometimes amounts 
to inflammation, may cause pain, and is sufficient to lower 
the hearing, even without the presence of anything obstruc- 
tive. I have seen symptoms of nervous disease result in 
consequence of the pressure from polypi; undoubtedly a 
certain amount of retained pus also aided in developing the 
symptoms. Dr. E. H. Clarke thought that it was rare for 
life to be endangered by polypi, but that it was not impos- 
sible. He cites a case where for two or three days previous 
to the extraction of a polypus the patient suffered from 
" headache, intolerance of light, nausea, vertigo, stupor, 
and fever." These symptoms disappeared after the re- 
moval of the growth. He further states that " the irrita- 
tion and inflammation induced in the ear and its neighbor- 
hood by the presence of a polypus may extend at any time 
to the brain." If the canal of Fallopius has in some por- 
tions only a membranous covering, as is sometimes the 
case, or if the bony wall is carious at any point, the press- 
ure of the polyp may cause facial paralysis. Hemiplegia 
very rarely has been observed as a consequence of the in- 
flammation of the tympanum, the result of polypi, and exten- 
sion to the meninges, as quoted by Burnett from Schwartze 
in the Archiv. f. Ohrenh., Bd. IV. p. 185. The membrane 
frequently does not heal after a polypus has been removed, 
although the discharge may entirely cease. The edges of 
the perforation may collapse so as to touch the promon- 
tory, to which it may become adherent. The intervening 
space of mucous membrane on the promontory will be cov- 
ered by a thick flat epithelium, having no moisture upon it 
and comporting itself like the skin. The meatus may be 
narrowed as a consequence of polypi, and become preter- 
naturally dry from atrophy or destruction of its sebaceous, 
hair, or ceruminous glands; sometimes, however, it will be of 
too great width. Frequently it is left in a state of chronic 
diffuse inflammation, the redness and tenderness remain- 
ing for a long time. Caries and necrosis of the temporal 
bone from the pressure of the polypi and the erosive action 
of the discharge, may result. In any event it seems clear 
that removal of the neoplasm is indicated to prevent nu- 
merous morbid changes in the ear. [A^ase recently came to my 
notice of abscess of the cerebellum, dependent on pus retained in 
the tympanum by obstructing polypi. The petrous portion was 
necrotic, and the roof of the tympanum carious in two places.] 



THE ARTIFICIAL DRUM MEMBRANE. 275 



THE ARTIFICIAL DRUM MEMBRANE. 

This may be used in certain cases of suppuration with a 
perforated membrane, but very rarely when the membrane 
is intact. Its object is to improve the hearing and close the 
drum cavity, so that it may be protected from atmospheric 
influences. It was first used by the laity more than two 
hundred years ago, and afterwards by the profession. It 
has been made of a great variety of materials. Yearsley 
selected a cotton pellet for the purpose, and in his book he 
has much to say about his new method of treating deaf- 
ness. Like all " new methods" it was rather extravagantly 
extolled, and after a few years fell somewhat into disuse. 
At the present time, however, it is being used more than 
formerly, and seems on the whole to be perhaps the best 
form of artificial ear drum. It has this great advantage that 
it is not likely to act as an irritating foreign body. More- 
over it will be seen, by reference to previous pages, that the 
cotton pellet is one of the modes of dressing a perforated 
membrane, in the method of dry treatment. Perhaps the 
best known artificial membrane besides this is Toynbee's 
(Fig. 81); it consists of a circular disk of sheet rubber 




G.Tl£MANN &.G0. 

Fig. 81. — Toynbee's Artificial Drum Membrane. 

(soft) fastened to a silver wire sufficiently long to reach to 
the membrana tympani. The rubber disk may require to 
be pared down by means of scissors, so as to accurately fit 
the canal. As Toynbee's disk is fastened by two round 
plates to the stem or handle, it sometimes becomes detached. 
To obviate this a mechanic in Nuremberg caused the end 
of the wire to be made into a spiral form so as to catch the 
rubber, as a cork-screw would hold a cork; the wire next to 
the tympanum was pushed backward through the rubber 
to prevent irritating the membrana. Lucae has covered 
the wire with a bit ot rubber tubing to prevent the unpleas- 
ant rattling of the unprotected wire in the ear. Gruber 
uses a similar piece of rubber to that of Toynbee, but 
attaches to it a piece of silk thread so as to draw it out 
of the ear when necessary. He claims that less irritation 



276 DISEASES OF THE EAR. 

results than with the Toynbee instrument. Beyond the 
use of soft rubber and cotton wool as materials for artificial 
drum membranes it seems unnecessary to go. The indica- 
tions for its use are as follows : any drum cavity that needs 
protecting from the air may be benefited by an artificial mem- 
brane ; whenever the ossicula are detached from each 
other, the result of destruction of their ligaments, or from 
failure of the membrane to keep them in proper contact, or 
even a severance of continuity consequent on relaxation of 
the ligaments, or absence of the incus, with a gap existing 
between the membrane and the stapes ; the latter also may 
be in a state of sub-laxation from relaxation of its annular 
ligament, requiring the presence of the artificial membrane 
to keep it properly in position. The artificial membrane 
by moderate pressure restores contact of these parts and 
presents an unbroken medium for the transmission of sonorous 
undulations to the oval window. 

Dr. Burnett, in his Treatise on the Ear (Phila., 1877), pre- 
sents a different explanation of the action of the membrane 
from that generally accepted (in a certain class of cases), 
which seems reasonable. Where the membrane has a large 
perforation with the ossicula in proper relation and the 
membrane is greatly retracted, in consequence of the non- 
resistance of a normal membrane to the action of the tensor, 
there is undue pressure on the labyrinth, and the indications 
are, not to press on the membrane to coaptate parts, but to 
draw it outward; this he does by tucking a bit of cotton 
wool beneath and behind the manubrium. The result is 
improvement to the hearing. He states that this may be 
the secret of the non-improvement to the hearing in so 
many cases where the artificial membrane is inserted in 
the ordinary manner. I had one case where a cotton pellet 
pressed upon an intact but relaxed and thinned membrana 
diminished a troublesome tinnitus, and improved the hear- 
ing. This condition, however, is exceedingly rare. 

The artificial membrane is contra-indicated where there is 
considerable discharge, or when granulations or polyps are 
present. If the discharge is increased by the wearing of 
the membrane, it must be discontinued. Sometimes tinnitus 
aurium, vertigo, nausea and irritation of the chorda tympani 
results from its use, when it should be discontinued. Any 
pain resulting from wearing it, is a contraindication. If 
the stapes is absent, the membrane should not be worn, un- 
less to protect the tympanum from the air. It should not 



THE ARTIFICIAL DRUM MEMBRANE. 277 

be worn constantly or at night; it is better to wear it for 
short periods only, especially if the hearing is considerably 
improved. The cotton pellet may, however, be worn for 
days together, only it should be kept clean. If one ear has 
normal hearing it is not advisable to use an artificial mem- 
brane for the fellow ear, unless it acts usefully in closing 
the cavity. 

There are several methods of applying the cotton pellet, it may 
be pushed down upon the membrane by means of a delicate 
pair of forceps, or a cotton holder may be twisted for two 
or three turns into the pellet, then carried to the proper posi- 
tion; by turning the holder in the opposite direction so as 
to disengage it, it may easily be withdrawn without distur- 
bing the cotton. The Toynbee membrane may be caught in 
the blades of any convenient forceps and carried to the proper 
position. The Gruber plate of rubber, with its silk thread 
attachment, may be inserted by appropriate forceps. 

Unless the artificial membrane touches the remains of the 
old membrane or the ossicula at exactly the right point, 
there is no improvement to the hearing. This is determined 
only by experiment. Sometimes the membrane must be 
introduced several times, before the right spot is reached. 
The hearing naturally is tested every time the membrane 
is readjusted. The patient himself may be taught how to 
introduce the membrane, and he often does it with great 
skill; his sense of feeling enables him to select the spot 
which before has been found to be the proper one. Fre- 
quently there will be no improvement at all to the hearing. 
I believe it is not used as often as formerly. About six 
years since, Dr. Spencer, of St. Louis, published an article 
on the use of the artificial membrane, which contained the 
opinions of a considerable number of aural surgeons in 
the United States, myself among others. The verdict was 
somewhat unfavorable to its use. It is a pretty scientific toy, 
and occasionally is very satisfactory in its effects. Dr. Blake 
of Boston has used a piece of writing paper, cut of proper 
size, moistened with water, and then by gentle pressure 
made to adhere to a smallish aperture in the membrana 
tympani. This acts both as a means of healing the per- 
foration and as an artificial membrane, and also as a pro- 
tection to the tympanum. On the development of the 
dermoid layer it will be pushed off; this process may occupy 
several weeks; then if the healing is not completed another 
is applied. The middle ear trouble must have well subsided 



278 DISEASES OF THE EAR. 

to make this plan successful. Dr. Knapp in the Archiv. 
Otol. for 1881, No. I., p. 64, treats of the cotton disk as an 
artificial drum membrane. He reports the case of a pa- 
tient, a woman, who wore it most of the time for twenty- 
nine years; the deafness previously was so great as to pre- 
vent her from mixing in society, obtaining an education, etc., 
and by the use of the cotton disk she was able to avail 
herself of all the advantages derivable from the possession 
of good hearing. The average opinion of the profession is 
in favor of using vaseline on the cotton previous to its in- 
troduction. It should be removed as often as necessary for 
cleanliness, but may be allowed to remain some days if not 
otherwise contraindicated. In the discussion at the Inter- 
national Medical Congress in London in 1881, a disposition 
was shown to increase the pressure of the Toynbee mem- 
brane from time to time, in order to maintain a maximum 
improvement to the hearing, although there were some 
dissenting opinions as to the propriety of doing this. 



MASTOID AFFECTIONS. 

PERIOSTITIS OF THE OUTER SURFACE OF THE MASTOID. 

This is the simplest and most frequent form of mastoid 
disease ordinarily met with in practice. 

Its usual mode of invasion is to travel outward from the 
tympanum, along the periostial lining of the osseous mea- 
tus, until the covering of the mastoid is reached. Then 
there will be redness and tenderness, swelling which pits 
on pressure, with possibly a greater degree of redness and 
swelling in the neighborhood of the insertion of the sterno- 
cleido-mastoid muscle. The canal must needs have ex- 
hibited some previous swelling, or redness, or tenderness 
on pressure. There may be some stiffness about the jaws, 
and the sub- and posterior auricular glands may be con- 
siderably swollen. The patient may have had pain in the 
ear and mastoid region, which often radiated more or less, 
over the whole side of the head. 

If the attack is severe, some fever and elevation of tem- 
perature may be observed. The tongue may be coated and 
the patient feel quite ill. The rule is that pus forms sooner 
or later. If left to itself it becomes a formidable disease; 
the scalp may be undermined with pus, so that half of the 



MASTOID PERIOSTITIS OF OUTER SURFACE. 279 

side of the head may be involved in the abscess, as in the 
case of John Scrypes, published in the JV. Y. Journal of 
Med. for Feb., 1873. The abscess had been allowed to re- 
main some weeks without opening, and had dissected up the 
scalp above the level of the lower portion of the mastoid 
process. The diameter of the abscess was at least three 
inches. The neck was not involved. 

It also sometimes follows the sterno-cleido-mastoid mus- 
cle, forming an abscess that extends far down the neck. In 
an ordinarily robust adult the external table of the mastoid 
is not likely to be destroyed, the disease not going beyond 
that of periostitis. It is true, however, that the sub-cutane- 
ous connective tissue frequently becomes involved, when a 
cellulitis is added to the other symptoms. The pain is 
likely to be severe, like all inflammations of the periosteum, 
especially if there is confined pus. Occasionally the ex- 
ternal table of the mastoid process gives way, and we have 
true mastoid cell disease. This is much more likely to 
occur in weakly subjects or those having any constitutional 
disease favoring destructive processes. In children it very 
frequently occurs, but this phase of the subject will be 
treated of under the head of mastoid cell disease. 

I do not conclude that there is much danger to the pa- 
tient's life in this form of the affection, it being a super- 
ficial matter mostly. 

In the treatment it is admissible to begin with mild meas- 
ures. If a poultice or leeches to the part promptly relieves 
the trouble, nothing more may be needed. I have seen 
Tr. of Iodine painted on the part until it became nearly 
black, discuss the inflammation. A saturated solution of 
Arg. Nit. will be still more effective, but it makes a hideous 
black crust, difficult to remove. I am compelled to admit 
that there is less indication for severe measures in this af- 
fection than I at one time thought. If these means fail, 
then the Wilde's incision must be done. A stout scalpel is 
introduced near the lower border of the mastoid, provided 
the swelling and redness extend so far; penetrate to the 
bone at once, extend the incision upward, parallel to the 
auricle and about half an inch behind, for the distance of 
one or two inches. Carefully note whether the knife glides 
smoothly over the bone. If there is any roughness, there 
is denuded, dead or carious bone. By pressing firmly on 
the part with the edge of the scalpel, a carious spot may 
often be broken through into the cells beneath, and a suffi- 
18 



280 DISEASES OF THE EAR. 

cient opening made for the evacuation of pus. It will be 
always desirable, even when no suspicion of bone involve- 
ment exists, to search the incision with a probe to see 
whether any rough or softened bone or fistulous opening 
exists. 

If the abscess extends downward in the direction of the 
sterno-cleido-mastoideus muscle, or any of the muscles in- 
serted into the mastoid process, a grooved director and 
bistoury may be used to freely lay open any burrowing 
sinus leading to an abscess lower down, or the abscess may 
simply be punctured at this lower point. Larger blood-ves- 
sels must be carefully avoided; but if an abscess is point- 
ing, it is likely that no important blood-vessels are in the 
way of an incision (the abscess having a tendency to sepa- 
rate blood-vessels as it comes to the surface). 

It will always be gratifying, in incising a mastoid swell- 
ing, to find pus, but often the surgeon will be disappointed. 
Where there is considerable cellulitis, the sense of fluctua- 
tion may be present without a particle of pus being subse- 
quently found. The relief from the bleeding and the di- 
vision of swollen and tense tissue, will often be very great. 
Again, the incision, after a day or two, may have permitted 
an abscess to open into it, which otherwise would have re- 
mained to inflict mischief upon the patient. Sometimes, I 
have by pressing firmly upon a swollen mastoid, caused the 
abscess to rupture into the meatus on its posterior wall, usu- 
ally near the junction of the osseous and cartilaginous por- 
tions. After making the incision, I am in the habit, if no 
pus is found, and the general appearance of the part in- 
duces one to suspect that there is pus somewhere, to pass 
in a probe and push it beneath the tissues near the bone in 
the direction of the focus of inflammation, to determine 
whether a pus cavity may not be opened into, and I have 
often succeeded in so doing. 

In a recent case, where a Wilde's incision failed to reach 
pus, and a day after, the abscess had ruptured into the mea- 
tus by a very small opening, I passed a probe through the 
incision in this direction, and easily succeeded in reaching 
the abscess cavity and diverting the discharge in the direc- 
tion of the mastoid incision. A probe ruptures no large 
blood-vessels, is not likely to do harm to nerves, and after 
the skin and connective tissue are divided, readily pene- 
trates the parts. Occasionally a mastoid abscess may point 
towards the posterior and outer portion of the meatus. 



MASTOID PERIOSTITIS OF OUTER SURFACE. 28 1 

When this is the case, the incision may be made at that 
point. Occasionally I have seen an abscess above the 
auricle, somewhat trenching upon the meatus. This may 
be opened above the auricle, or in the upper and outer 
portion of the meatus, that is, where it evidently points. 
In this region it may involve the temporal bone and open 
into mastoid cells, but this is very infrequent indeed. 
Sometimes the inflammation, extending from the tympa- 
num, may involve the parts in front of the meatus, when cel- 
lulitis with considerable swelling may result. This is a 
somewhat annoying location for an abscess. In making an 
incision there is great danger of dividing some of the larger 
branches of the temporal artery or even that vessel itself. 
The incision should be commenced above the swelling and 
quite near to the auricle, and not extend too far downward, 
or it may be made in the anterior portion of the meatus. 
With a stout probe or grooved director endeavor to open 
into an abscess cavity, if the incision has failed to do so. 
The director will exhibit a small amount of pus in its 
groove if it has penetrated an abscess. After the incision 
has been made, it will be well to use a poultice for a few 
days; not long enough, however, to macerate the parts, for 
granulations are prone to spring from these incisions, and 
the poultice facilitates their growth. It is my own prac- 
tice to daily open the incision with a probe, moving it 
from side to side in the lips of the wound to prevent adhe- 
sion, and maintain a perfect opening into the abscess cav- 
ity. The method practised by many, however, is to insert 
a tent, and thus keep the wound open. My objection to 
that mode is, that while the tent is in position a confined 
pus cavity is formed for the time, which cannot but dimin- 
ish the promptness of recovery. Any good disinfectant wash 
may be used, at least once a day, to cleanse the wound. 
This may, if necessary, be introduced by means of a syringe. 
If, after the first relief from an incision, the patient again 
has pain, with possibly fever and elevation of temperature, 
it is well to search the wound for some concealed pus cav- 
ity, which indeed may result from closure of the wound al- 
ready made in some unobserved portion, and finding it, the 
patient will experience relief from its evacuation, as in the 
first instance. The wound should be kept open until noth- 
ing remains of the disease. Pain in the mastoid or side of 
the head should have completely disappeared. All proper 
care should be taken to prevent relapses. The matter of 



282 DISEASES OF THE EAR. 

carious or softened bone will be considered under the head 
of Mastoid Cell Disease. Granulations at the edge of the 
incision will sometimes be very embarrassing: these may 
be clipped off with scissors or a scalpel, or removed 
by forceps, and the point of attachment thoroughly cau- 
terized with arg. nit. in saturated solution or stick, or 
nitric acid. In making these incisions, arteries are some- 
times divided, but torsion will usually arrest the haemor- 
rhage; if not, apply a ligature. Sometimes an aneurism 
of the posterior auricular artery may result from the 
wounding of the vessel in making the incision. Dr. Buck, 
in the Tr. Amer. Otol. Soc, 1873, p. 61, reports a case of 
aneurism of the posterior auricular artery. An incision of 
the mastoid was done somewhat nearer the auricle than 
usual, which was followed by a small jet of arterial blood. 
It was arrested by compression, as it seemed impossible to 
apply a ligature. Five days later distinct pulsation was no- 
ticed over the wound; on the next day a circumscribed pul- 
sating tumor, the size of a hickory nut, made its appear- 
ance; on the day after, pulsation ceased and the tumor 
diminished in size ; an incision in the line of the former 
wound was made, and a blood clot was removed from a dis- 
tinct cavity. Haemorrhage recurred, and the part was 
stuffed with lint. Two days after, on removing the lint, a 
jet from an artery was observed, when the cavity was again 
stuffed, and a compressive bandage was applied. The lint 
was allowed to remain until it ulcerated its way out. 
There was no further trouble. Other cases of aneurism 
from a similar cause have been reported, but this one pre- 
sents all the characteristics of such an accident. [If a large vein 
be divided, pressure will arrest the haemorrhage.] 

PRIMARY INFLAMMATION OF THE MASTOID AND ITS CELLS. 

This very infrequently occurs. The rule already laid down 
is, that the disease is always secondary to middle ear inflamma- 
tion or that of the meatus. A few cases on record prove that 
there are exceptions to this rule. In the N. Y. Med. Record 
for June 4, 1881, p. 634, Dr. E. Gruening, of N. Y., reports 
a case as follows : A man had, in October, 1880, hardness of 
hearing and tinnitus, with stiffness of the neck. On No- 
vember 3d the doctor saw him, when he had pain in the 
mastoid, but no swelling ; some redness. He could not hear 
anything but the tuning-fork. There was no disease of the 



PRIMARY INFLAMMATION OF THE MASTOID. 283 

ear. The membrana tympani was perforated by a needle, 
and leeches were applied to the mastoid, but no relief was 
experienced. On November 6th Wilde's incision was done 
with temporary improvement. On November 12th had a 
severe rigor, and the next day he vomited. On the 16th of 
November the mastoid was opened with Buck's instrument 
and ten drops of pus escaped. The hearing was then much 
improved, and now, January 28th, 1881, the hearing is nor- 
mal except that he has a little tinnitus. In a large number 
of cases of osteo-sclerosis of the mastoid the trouble seems 
to have developed so long after the middle ear affection oc- 
curred as to entitle it to the name of a primary affection. 
Mr. Dalby, in the Medico-Chirurg Transactions, vol. 62, p. 237, 
states that the mastoid cells become sometimes primarily 
inflamed, while throughout the course of the disease the 
tympanum remains healthy. Dr. Arthur Hartman, in the 
Archives of Otology, N. Y., 1879, p. 322, translated by Dr. J. 
A. Spalding, speaks of an idiopathic chronic periostitis of 
the mastoid process leading to osteo-sclerosis, which may 
be developed long after the middle ear is free from disease. 
Dr. H. Knapp reports a case of " primary acute periosti- 
tis of both mastoid processes" in the report of the first 
otological congress, N. Y., 1876, p. 80. He quotes from 
Voltolini and C. J. Blake, who both agree that this affection 
is possible. They also furnish cases to illustrate the subject. 
Knapp's case is that of Mrs. H., aged 20. In March, 1876, 
she had pain in the left ear, but no disturbance in the hear- 
ing. Soon the skin over the mastoid region became red, 
swollen, and tender; not being properly treated it grew 
worse. The pain subsequently extended to the mastoid 
and neck. Dr. Knapp first saw her on March 14th, 1876, 
one week after the disease had commenced. She was then 
feverish, with loss of appetite, and in bed. The pain was in 
the left ear and neck. Besides the mastoid swelling previ- 
ously stated, the skin on the posterior surface of the auri- 
cle was red, swollen, and raised. At the mastoidal attach- 
ment of the sterno-cleido-mastoideus muscle, for the dis- 
tance of an inch down the tendon, was a swelling which 
was tender to the touch. Leeches, morphine, etc., did no 
good. On the fifth day fluctuation appeared, and the mas- 
toid was incised to the bone, dividing the periosteum and 
permitting a small amount of pus to escape. The discharge 
ceased after the usual treatment in four days, and the 
wound closed — was cured in ten days after the incision. 



284 DISEASES OF THE EAR. 

The mastoid was sensitive to cold for three months after- 
wards. On April 24th, eight weeks after the beginning of 
the disease in the left ear, without any known cause she 
had pain behind the right ear and over the head. On the 
next day there was redness, swelling and tenderness be- 
hind the ear. On the the third day worse, and leeches and 
morphine were used; but in spite of these she was so much 
worse in two days that an incision was made over the mas- 
toid although there was no fluctuation. No pus was found. 
She was cured in five days; did not relapse. This ear, like 
the other, was free from disease, thus differing from some 
other cases where at some past time the ear had been dis- 
eased. The doctor calls attention to the swelling of the 
mastoidal insertion of the sterno-mastoid, and infers that 
this indicates a mastoid periostitis. Voltolini's case did not 
present this swelling, and he thinks it only an inflammation 
of the subcutaneous cellular tissue of the mastoid. His own 
case, he was at first inclined to think might have cerebral 
complications, especially phlebitis and thrombosis of the 
cerebral sinuses, as according to Griesinger obstruction 
of the sinus near the sigmoid fossa produces a painful 
oedema over the mastoid process. The independent char- 
acter of the inflammation in these cases is worthy of note 
and cannot be explained. This affection does not seem to 
undergo resolution. The treatment is the same as already 
laid down. 



INFLAMMATION OF THE MASTOID CELLS 

usually depends on an inflammation of the tympanum, this 
inflammation extending by continuity of the muco-periosteal 
lining common to both the tympanum and mastoid cells to 
the latter. Any variety of inflammation of the tympanum 
may extend to the cells, whether it be a mild form of ca- 
tarrhal otitis or the most violent form of purulent inflamma- 
tion. This process may be acute or chronic, or what perhaps 
is more frequent, an exacerbation in a chronic inflammation. 
Mastoid periostitis may cause destruction of the outer table, 
coveing the mastoid cells, and involve this region. 

The swelling of the soft parts in this form of the disease 
may resemble very closely that in simple mastoid periosti- 
tis. There is, however, a very rare form of the disease, 
which has been most ably described by Bezold in the 



MASTOID CELL DISEASE. 285 

Deutsche Med. Wochenschrift, July 9th, 1881. The mastoid 
becomes perforated at its inner surface in the digastric 
fossa. It may have been swollen over its whole surface, 
but on the advent of this complication the tendons of the 
muscles inserted into the process become so swollen as to 
apparently partially obliterate the original mastoid swell- 
ing. This may go on until the region occupied by the 
sterno-cleido- mastoid, the splenius capitis, and the trach- 
leo-mastoid becomes deeply infiltrated and the whole side 
of the neck much swollen, exquisitely painful, hard, and at 
first with no signs of fluctuation. Somewhat early in the 
disease an abscess may point at the posterior part of the 
meatus. Pressure on the swollen muscles will cause the 
pus to be extruded at this opening, and also into the mastoid 
if that has been previously perforated. The swelling 
from the confined pus may extend as high as the superior 
semi-circular line of the occiput, as it is impossible to break 
through the tendon of the trapezius, which is also closely ad- 
herent to the tendons of the mastoid muscles. This is 
accompanied by severe pain in this region, from pressure 
upon the occipitalis major nerve at its point of entrance 
into the complexus magnus. In a somewhat advanced stage 
of the disease fluctuation may be detected, but the pus is 
at some distance from the surface and requires deep inci- 
sions for its evacuation. 

In inflammation of the meatus, especially at its upper 
and posterior part, where the periosteum is involved, the 
partition wall between the cells and the meatus may give 
way and true mastoid cell disease result. 

The ordinary consequences of mastoid cell disease are about 
as follows : In a certain class of cases there will be a violent 
and destructive inflammation, resulting in the formation of pus 
and perhaps a carious breaking down of the osseous parti- 
tions between the cells, so that the mastoid process may 
contain but a single large cavity, but it may continue to 
destroy bone in its neighborhood until in some instances 
most of the temporal bone may be thrown off in a carious 
condition. Again the inflammation may be of a milder type, 
and instead of destroying tissue will result in an inflamma- 
tory proliferation, the cells undergoing a process of osteo- 
sclerosis, which may convert the mastoid into a solid bony 
mass, often of petrous hardness, a state of eburnation, or 
ivory-like. In the earlier stages of this development the 
proliferation material may be exceedingly soft, but ulti- 



286 DISEASES OF THE EAR. 

mately the true bony quality will be developed. The pain 
in mastoid cell disease is dependent on the following 
causes: Confined pus is sufficient to excite severe pain here 
as in other parts of the body. Intense hyperemia, causing 
pressure on sensitive nerves, is often a sufficient cause for 
pain. In those cases where there is no external manifesta- 
tion of mastoid trouble, or, we might almost say, of tym- 
panal disease, where the symptoms of osteo-sclerosis have 
been found to exist, there may be considerable aching pain, 
due undoubtedly to pressure of the proliferating material 
upon branches of the tri-geminus, or on sensitive filaments 
of other nerves supplying the mastoid cell region. 

Mode of Invasion. — The mastoid is not as likely to be in- 
volved during the acute stage of a tympanal inflammation, 
or, at least, not until the disease has made some progress. 
The first hint of a commencing mastoid trouble may be in 
the fact that the ordinary means for the relief of the acute 
symptoms have failed, and the patient still has pain in 
spite of leeches, fomentations, douching with hot water, 
and the administration of opiates. Another frequent mode 
of invasion is during a chronic suppurative otitis, which 
undergoes an exacerbation when the mastoid becomes im- 
plicated. 

In a severe acute inflammation of the tympanum the 
periosteum of the meatus near the membrana tympani fre- 
quently becomes inflamed. This may not result in resolu- 
tion; the periosteum may be separated from the bone, and 
the latter, deprived of nutrition, undergoes caries. If this 
should occur on the upper, posterior, or inferior wall- of the 
meatus, it is likely to open into the mastoid cells. A toler- 
ably frequent experience is to find a fistulous opening at 
the inner extremity of the meatus, on its posterior wall, 
which may give rise to a discharge, even after the mem- 
brana tympani has healed, and the tympanic trouble come 
to an end. 

Furuncles of the meatus may sometimes involve the peri- 
osteum of the osseous meatus, and extend direct to the 
mastoid cells. 

In periostitis of the outer surface of the mastoid, the 
cells are involved in a certain number of cases. The 
periosteum becomes destroyed, and the bone beneath dies 
from mal-nutrition, and a carious opening into the cells 
is the result. In adults this is not often likely to take 
place; but in children this seems to be perhaps as frequent 



SYMPTOMS OF MASTOID CELL INFLAMMATION. 287 

a mode of involving the cells as any other. It is possible 
that the opening into the antrum, the result of a Wilde's 
incision, in children, may, more frequently than we are 
aware of, depend on the knife's crashing into the cells, from 
pressing too hard during the incision. In most of the cases 
of swelling and inflammation of the mastoid in children that 
I have incised, the knife has entered the antrum. Bezold, 
in the Deutsche Med. Wochenschrift, July 9, 1881, describes a 
rather exceptional manner in which mastoid cell disease in- 
volves the muscles of the neck. He has found that in some 
cases the mastoid bone at the digastric fossa, that is, on the 
inner surface of the process, contains numerous cells, which 
approach so near the surface of the bone that it is readily 
cut into with a knife, or even a probe may break through. 
In some cases there is an absence of bony covering, and the 
cells may be covered by the soft parts only. Numerous 
foramina for the passage of blood-vessels still further facili- 
tate the passage of inflammation outward. 

At this unprotected point the pus escapes, and burrows 
deeply among the muscles of the neck, extends upwards 
as far as the superior curved line of the occiput, and back- 
ward to the ligamentum nuchae, and downward as far as 
the lower cervical or upper dorsal vertebra. Such cases 
usually terminate fatally, either by exhaustion, or by in- 
volvement of the vertebrae or base of the cranium, with 
symptoms of paralysis; by oedema glottidis, or by bur- 
rowing of pus in the thoracic cavity. In one of his fatal 
cases there was, during the last weeks of life, paresis of 
both upper extremities, stiffness of the neck, and great dif- 
ficulty in swallowing. At the time of death there were 
symptoms of oedema of the lungs. Deep incisions and 
drainage caused a few of these cases to recover. The mus- 
cles inserted into the mastoid process cover its postero-in- 
ferior portion by their tendons, and also by that of the 
trapezius, which is continuous with them, so as to present 
a resisting wall, through which it is impossible for pus to 
pass; hence the burrowing along the course of these mus- 
cles. 

Symptoms of Mastoid Cell Inflammation. — The subjective 
symptoms are more valuable than the objective, and are as 
follows: After an acute attack of inflammation of the tym- 
panum, the symptoms sometimes do not disappear after 
ordinary means of treatment have been used; there still is 
pain about the ear, but more especially in the mastoid re- 



288 DISEASES OF THE EAR. 

gion, which may radiate to almost any portion of the side 
of the head. There may or may not be fever, a coated 
tongue, with elevated temperature, vertigo, with a ten- 
dency to fall toward the opposite side, nausea, vomiting, 
sensitiveness to loud noises or a strong light, with slug- 
gishness of the intellect, or preternatural activity; some- 
times delirium or even convulsions. In short, there may in 
some cases be signs of irritation of the meninges, which do 
not differ from the symptoms that indicate real cerebral 
complications. There may or may not be considerable 
deafness, with tinnitis aurium. The pain is more likejy to 
give trouble at night, and the patient may be unable to 
sleep. In some cases the haggard, anxious look will indi- 
cate the amount of distress he has undergone. Sometimes 
the fever accompanying these symptoms may be intermit- 
tent in character, with rigors, resembling that from mala- 
ria. The respiration may be preternaturally rapid, or the 
opposite, and the pulse may be irregular and weak, show- 
ing possibly that some portion of the pneumogastric nerve 
is involved in the disease. In rare instances the pupil may 
be sluggish or dilated, and in others contracted. Facial 
paralysis is occasionally seen, and very infrequently hemi- 
plegia of the opposite side. 

Difficulty of deglutition occasionally occurs. If the cav- 
ernous sinus is diseased, there may be paresis of those 
nerves passing in its vicinity (the 3d nerve, the ophthalmic 
division of the 5th and the 6th nerve). It is well-nigh im- 
possible to diagnosticate during life, as to whether the brain 
or its meninges are involved, as brain symptoms and those 
dependent on the irritation set up by the ear affection may 
be of a similar character. If we are dealing with a case of 
mastoid cell osteo-sclerosis, which may have developed from 
a mild catarrh of the tympanum, it is impossible, certainly, 
to determine the presence of this condition except by opera- 
tion. A moderate amount of pain in the mastoid region 
and side of the head may be all the symptoms obtainable. 

The patient may during the day be free from pain, but 
towards evening, when becoming fatigued, the pain may 
recur. If he has taken cold, and added to his aural ca- 
tarrh, the symptoms about the mastoid are likely to be 
aggravated. 

The Objective Signs are somewhat less equivocal. In an 
uncomplicated case of osteo-sclerosis, however, there may 
be no symptoms apparent on an examination. If there is 



SIGNS OF MASTOID CELL DISEASE. 289 

suppuration and dead or denuded bone, there will be the 
following symptoms: In the upper and posterior part of 
the tympanum, granulations or polypi may make their ap- 
pearance, which often recur, after having been removed, 
even in spite of the most effective cauterization. A persist- 1 
ent discharge from the tympanum often owes its presence 
to diseased mastoid cells. In the meatus a persistent in- 
flammation of its posterior wall, in the osseous portion, 
may be due to mastoid cell trouble. 

If there is in this region one or more fistulous openings, 
which often may be fringed with granulations, there is the 
strongest suspicion that disease of the cells is at the bottom 
of the difficulty. Externally, the disease may have broken 
through the outer table, and possibly a fistulous opening 
in the soft parts will indicate its position. In other cases 
the bone in this region may be necrosed, and no suspicion 
(judging from the appearance of the soft parts) of its exist- 
ence may be excited. The latter, however, are frequently 
paler than the neighboring region, and may have an under- 
mined doughy feeling to the touch. A case is reported by 
Dr. Arthur Mathewson, in the Tr. Amer. Otol. Soc. for 
1878, p. 270, in which an epithelial tumor of the tympanum 
extended into the cranial cavity, excited a very intense 
otitis media and mastoid cell inflammation, which had com- 
pletely destroyed the whole of the mastoid and petrous 
portions of the temporal bone, and the soft parts covering 
the mastoid showed no signs of disease. An incision into it, 
however, was made, somewhat reluctantly, which of course 
revealed the true state of things. 

In other cases the ordinary signs of inflammation of the 
periosteum of the outer table of the mastoid will be exhibited. 
Pus is usually found in this form of inflammation. A very 
striking symptom of burrowing pus will be observed in the 
position of the auricle, which may stand with its posterior 
face at right angles to the side of the head. This is easily 
explained, as the antrum mastoideum is just behind and 
almost beneath the middle insertion of the posterior part 
of the auricle, and as that is usually the focus of mastoid 
cell inflammation, formation of pus is more likely to occur 
there; while if the trouble is only mastoid periostitis of its 
outer plate, the abscess will usually point lower down. 
There is a strong tendency of abscesses resulting from 
mastoid cell disease to burrow beneath some of the mus- 
cles inserted into the mastoid process. Conspicuously is 



29O DISEASES OF THE EAR. 

it so in the abscess which follows the sterno-cleido mastoid 
muscle downward. They may reach the clavicle. Sometimes 
the side of the neck will be swollen in the direction of the 
trachleo-mastoid. A frequent seat of mastoid abscess from 
disease of the cells, according to Bezold, is on the inner 
side of the process, in the digastric groove. When several 
of these muscles are the seat of abscess, the whole side of 
the neck may be intensely swollen, very hard, and painful, 
rendering it almost impossible for the patient to move his 
head. Such cases, however, are rare. 

The swelling in the vicinity of the stylo-mastoid foramen 
may be so great as to produce temporary paralysis of the 
facialis. I recently saw a case of this kind at the hospital. 
Sometimes abscesses point on the posterior wall of the 
meatus, and are very painful. Another sign of mastoid cell 
disease is tenderness of the region when firmly pressed 
upon, or, better still, when percussed smartly with the finger 
tips. It may not excite pain in the immediate part, but if 
there are shooting pains in the side of the head consequent 
on the percussion, suspicion points to mastoid cell trouble. 

Treatment of Mastoid Cell Disease. — The leading indications 
in the management of mastoid cell disease are: 

1st. Diminish the hyperemia and swelling of the parts by 
appropriate treatment. 

2d. Where there is reason to believe that products of 
inflammation are confined in any cavity, to make a free 
opening so as to allow the readiest exit possible for such 
products. 

3d. Where carious or necrotic bone exists, to cause its 
removal if doing harm, or use such means as shall resist the 
progress towards further destruction. During an attack 
of acute inflammation of the tympanum an uncomfortable 
or even painful sensation may be experienced in the mas- 
toid region, with no external trouble which may point to 
inflammation of the mucous lining of the cells. This con- 
dition may be relieved by three or four leeches on the mas- 
toid region, or by a poultice, or in some instances an ice 
bag. This condition is usually not serious, the inflamma- 
tion never going beyond the catarrhal form. The pain is 
'probably dependent on swelling of the lining of the cells, 
so that the spaces are more or less obliterated and the 
lining membrane may be " pinched " by the too sharp coap- 
tation of its opposing surfaces. The general hyperaemia of 
the part will also result in pain, as is the case in almost 



TREATMENT OF MASTOID CELL DISEASE. 2gi 

any other tissue. When the soft parts on or in the neigh- 
borhood of the mastoid are swollen, as a consequence of 
the cell disease breaking through the external plate of the 
mastoid, the treatment should be as follows: Any point 
of fluctuation should at once be freely opened by an inci- 
sion reaching quite to the bone, so as completely to divide 
the periosteum. If the swelling is on the mastoid, commence 
the incision at the lower portion of this bone, about half an 
inch from the auricle, to avoid the posterior auricular 
artery, and carry it upwards for from one to two and a half 
inches, that is, sufficiently far to freely divide all the swollen 
tissue. After the incision has been made pass a short 
probe into it in order to find the opening into the mastoid 
cells. As the antrum is the most frequent site of carious 
processes, the attention may be directed more particularly 
to that region. 

Abscesses following any of the muscles on the neck may 
be sought for, especially those burrowing in the direction 
of the sterno-cleido-mastoid the trachleo-mastoid or the sple- 
nius-capitis muscles. Often the collection of pus will be 
found some distance from the mastoid. An abscess which 
has burrowed along the course of the sterno-cleido-mas- 
toid may point near the clavicle. There is no objection to 
the use of the poultice previous to an incision, but it should 
not be continued long enough to soften the parts unduly. 
In making the Wilde's incision considerable force may be 
applied to the scalpel, with the hope that it may break 
through the softened bone and sufficiently open into the 
cells. This can nearly always be done in young children. 
After abscesses have been opened, a poultice may be used 
for a few days and a tent introduced to keep the incision 
from closing, or a drainage tube may be inserted of soft 
rubber or silver. A plan I like, however, is that of passing 
a probe along the lips of the incision daily to prevent clos- 
ure, and at the same time press out any pus that may have 
collected. A variety of disinfectants may be used to cleanse 
the abscess from any foul material. In the burrowing ab- 
scesses of the muscles, it may be well to inject a solution 
of acid, carbolic, a drachm to the pint of water, once a day 
in the direction which the pus has taken, to encourage the 
closure of the pus tract. It may, however, be necessary 
after a time to lay open the somewhat fistulous canal pro- 
vided it shows a disinclination to close spontaneously. 
Sometimes these abscesses tax the constitutional energy of 



292 DISEASES OF THE EAR. 

the patient so that nourishment and stimulants must be 
resorted to to sustain the failing strength. The mastoid 
abscess requires the most careful attention. It will be well 
to syringe the ear with the carbolic acid solution or salt 
and water, with the hope that it will pass out through the 
opening in the mastoid. This failing, the syringe may be 
inserted into the latter, and the attempt made to pass the 
solution through the middle ear from this direction. In this 
condition the membrana tympani is ruptured, so that it may 
be easily done. The irrigation should be repeated at least 
once a day. If there is a free passage through the mastoid 
opening to the tympanum, and the pain and other symptoms 
subside, nothing more may need to be done. Recently I 
had a case of mastoid abscess in a little child with purulent 
otitis. The cells were opened by Wilde's incision. Water 
could not be forced into the tympanum through the incision, 
but she made a good recovery without further surgical 
interference. One of the striking improvements noticed 
was the rapid subsidence of the purulent discharge from 
the ear after the incision. When the abscess has already 
ruptured nothing more maybe required provided the open- 
ing is sufficient. If not it must be enlarged. It is also 
desirable that the opening in the mastoid communicate 
with the tympanum. 

Granulations are likely to form about the incision, which 
may be removed by snare, forceps or cauterization in the 
usual manner. They may also spring from the mastoid 
cell cavity, requiring removal. Under the head of polypi 
an important case of this kind is referred to. In cutting 
down on the mastoid a small fistulous opening occasionally 
may be found even where there has been no swelling of 
the soft parts, or an abscess has imperfectly healed and left 
a passage extending from the soft parts to the mastoid 
cavity. In such cases if there is any evidence present of 
confined pus or other products of inflammation, this fistu- 
lous opening must be enlarged, the carious borders chip- 
ped or scraped away, and a free communication with one or 
more of the larger mastoid cells made. 

A case reported by Dr. C. R. Agnew, in the Tr. Amer. 
Otol. Soc. for 1865, will illustrate this point. Miss X., in 
the middle period of life, had an attack of mastoid perios- 
titis resulting from disease of the tympanum. An incision 
was made down to the bone, and the latter was opened by 
boring with a gimlet. Pus came from the incision, and 



OPERATIONS ON THE MASTOID. 293 

from the perforation of the mastoid; the patient was re- 
lieved. One year after this the Doctor found a fistulous 
opening in the mastoid extending through the soft parts to 
the antrum. She was deaf, had pain in the temporal bone, 
was nervous, anxious, and could not sleep well. It was 
concluded that there was thickening of the brain covering 
near the ear in consequence of basilar trouble. There was 
no rough or carious bone found. She became somewhat 
better, then had a relapse, when there occurred facial 
paralysis, vomiting, and difficulty in articulation; had a 
vacant look; concluded that the pneumogastric was slight- 
ly involved. There was pain also behind the well ear. A 
half-inch trephine was used in operating, the pin of the 
instrument being inserted into the fistula. The disk of bone 
removed was three eighths of an inch in thickness and only 
contained one small cell. This operation not opening the 
sinus to the bottom, the opening was still further enlarged 
to a depth of five eighths of an inch. No pus or diseased 
bone was found, but the patient made a fairly good recov- 
ery. The Doctor thought that here we had to deal with 
an ostitis with hyperplasia filling a few or all of the mas- 
toid cells. 

General Indications for the Opeiiing of the Mastoid Cells. — 1st. 
If on cutting down upon a swollen mastoid where the bone 
is roughened and the periosteum removed and perhaps 
carious openings extend into the cells, the symptoms at once 
completely give way, no further proceedings may be neces- 
sary unless there is a communication with the tympanum, 
when it is always desirable to pass a stream of carbolized 
water into this opening and through the middle ear to the 
meatus. If no relief results from the Wilde's incision, then 
the cells must be opened, whether the external table be 
diseased or not. A perfectly healthy condition of this bone 
does not contraindicate an operation. Nay, in some cases 
where the external plate is exceptionally developed, the 
tendency of the disease may be to pass inward or upward, 
attacking a bony sepfcum which has much less power to re- 
sist a morbid process than has the other surface. Especially 
is this the case at a point internal to the antrum, near the 
sigmoid flexure of the lateral sinus. Again, this tendency 
to extend inward becomes greater when all of the smaller 
cells have been obliterated by osteo-sclerosis, leaving the 
outer plate still more fortified by accession of new bone. 
2d. When the mastoid region seems perfectly free from dis- 



294 DISEASES OF THE EAR. 

ease, but the patient has recurring polyps of the tympanum 
which may be attached at or near the opening of the an- 
trum, and no means at our disposal prevent their recurrence, 
it will be proper to open the cells. 3d. In a case of osteo- 
sclerosis whether any disease of the tympanum remains 
or not, and the patient has tenderness in the mastoid on 
sharp percussion, or even if he does not, but if a persistent 
pain is experienced in the mastoid process which may 
radiate to different parts of the side of the head, relief may 
be expected from opening into the cells. 4th. If a seques- 
trum is found in the mastoid cell cavity, it is generally 
proper to remove this, although it is often safe to allow it 
to separate by natural processes. The case of John Edding- 
ton will illustrate that point. It is as follows: His age 
was twenty months; applied for treatment July 26th. Has 
a purulent inflammation of the tympanum of three months' 




Fig. 82.— Sequestrum from the Case of J. E., Showing both Surfaces of the Bone. 

duration. A pale looking boggy swelling without distinct 
signs of fluctuation appeared over the mastoid; this was in- 
cised without evacuating pus. In two days pus made its 
appearance; previous to the incision there were head symp- 
toms which disappeared after the operation on July 28th; 
there was considerable cellulitis extending above and in 
front of the auricle. An incision was made enlarging the 
old wound upward and forward; bone rough and of unequal 
depth. Sept. 1st the boggy swelling extending still further, 
the incision was again made in the same direction as be- 
fore; opposite the antrum the probe suddenly passed into 
the mastoid cells for a distance of half an inch. The patient 
did moderately well during the next three months, although 
the swelling extended to the front of the auricle. Early 
in the treatment, water was passed freely from the incision 
in the mastoid through the tympanum. 



INDICATIONS FOR OPENING INTO THE MASTOID. 295 

About six weeks from the commencement of the treatment 
facial paralysis occurred; on Oct. 1st a piece of dead bone 
was observed in the region of the antrum which was at first 
immovable, but after a week or two it could be moved about 
in a limited manner — it seemed to extend to a considerable 
distance. In one month the sequestrum was caught by 
forceps and moderate traction made, but as consideralbe 
hemorrhage resulted, no further effort was made to remove 
it. On Dec. 26th, or about one month after this, the mother 
returned to the hospital bringing the sequestrum with her 
(Fig. 82), which had separated spontaneously; it consisted of 
nearly the whole of the temporal bone with the exception of 
the inner part of the petrous portion, and a little of the in- 
ferior wall of the osseus meatus. The facial paralysis was 
less apparent than at first. One month after this a swell- 
ing extended downward from the old opening which was 
relieved by incision. Subsequently the child made a good 
recovery. This patient belonged to Dr. Agnew's clinique at 
the College of Physicians and Surgeons, and it is through 
his kindness I am permitted to report the case. He also 
aided me materially by his advice. During the whole course 
of this case there was no question as to the advisability of 
abstaining from any measures more heroic than those 
practised. 

On the Different Modes of Operating on the Mastoid Cells. — 
The instrument longest used and best known for this purpose 
is the Trephine. It should be of small size, ranging from 
something less than one fourth of an inch to one half an 
inch in diamater. After making an incision in the soft 
parts of about two inches in length, a half inch behind the 
auricle, the periosteum is turned back, if not already 
separated, and the trephine applied over a point directly 
behind the meatus, at a distance of \ to -J- inch, but not ex- 
tending above its upper wall, so as to avoid the sigmoid 
flexure of the lateral sinus. The boring should be done 
very slowly and cautiously, stopping frequently to deter- 
mine by a probe or a delicate wedge shaped instrument as 
to whether the disk of bone has become loosened; if so, do 
the subsequent cutting on the side which is still immova- 
ble. If after removing it there is no communication with 
the tympanum, or if any fistulous opening is found, the 
operation may be completed by going deeper with a gimlet 
or hand drill or one propelled by the dental engine, or a 
small chisel, and open as far as seems necessary to obliter-' 
19 



296 DISEASES OF THE EAR. 

ate any fistula or to open a communication with the tym- 
panum. Sometimes when the mastoid cells are obliterated 
by osteo-sclerosis, a considerable distance may be reached be- 
fore the disk of bone can be removed. Dr. D. R. Ambrose, 
of New York, is reported by Dr. Roosa in his " Treat- 
ise on the Diseases of the Ear," 1873, p. 431, in a case 
of osteo-sclerosis of the mastoid where a disk of bone one 
inch in length was removed by a J inch trephine. The Doctor 
was careful to avoid the lateral sinus, and no accident re- 
sulted. In general it is not safe to go so deeply, although 
if the line of the petrous portion of the temporal bone is 
followed, a great distance may be travelled without reach- 
ing the brain, but the semi-circular canals would certainly 
be broken up. If the region of the antrum is reached it is 
ordinarily not necessary to go further. By following these 
directions, the only danger to be apprehended is the wound- 
ing of or opening into the lateral sinus especially at its 
anterior portion nearly opposite the antrum. 

Bezold, in the Deutsche Med. Wochenschr., July 9, 1S81, 
concludes from measuring 100 temporal bones that the mas- 
toid portion varies greatly in size in different subjects, and 
that the relations of the lateral sinus (transverse) to the an- 
trum is by no means constant, so that in opening into the 
cells according to the ordinary method there is danger of 
wounding the sinus. He proposes therefore to lift the 
auricle somewhat from its attachment and enter the antrum 
beneath it at a point still nearer the meatus than is usual. 
He quotes Hartman as having done this operation 100 
times on the cadaver, and that he arrived at about the same 
results that he himself had. Hartman calls attention to 
the fact that it is possible to wound the dura mater at the 
middle fossa of the base of the cranium when the perfora- 
tion is made at a point a little too far above the upper border 
of the auditory canal. Other points have been selected for 
entering the mastoid. A fistulous opening is usually 
selected as a point of entrance for the instrument. Dr. 
Buck in his book on the diagnosis and treatment of dis- 
eases of the ear published in Wood's Library in 1880, reports 
a case where he opened the mastoid at its lower portion, 
hoping to take advantage of gravity in more perfectly 
draining the cells, but he found little or no communication 
between this and the upper part of the process; probably 
on account of closure of the cells from inflammatory pro- 



INSTRUMENTS FOR OPENING THE MASTOID. 297 



liferation. Subsequently the mastoid required to be opened 
over the antrum in the usual manner. 

Bezold on the contrary, recommends perforating the 
lower extremity of the mastoid so as to completely open 
both the inner and outer surfaces at the digastric fossa. 
He regards this as sufficient for the drainage of both the 
mastoid and the tympanum. He reports a case of success- 
ful performance of this operation on a peasant, aged 73, 
who recovered in fourteen days. 




Fig. 83. — Buck's Drills for Opening the Mastoid. 

Some form of hand drill is just now very much in vogue 
for opening the mastoid. The one figured here is known 
as Buck's (Fig. 83). I believe it to be the best instrument 
for the purpose I am acquainted with; the inventor of these 
drills prefers the larger one to the smaller. To prevent it 
suddenly going too deeply he is in the habit of extending 
one of the fingers of the hand holding the drill so as to rest it 



298 DISEASES OF THE EAR. 

against the side of the head. This drill has a wide applica- 
tion. A great variety of shapes may be used, and the den- 
tist's engine may be utilized for the purpose of driving 
them. .[For this purpose the drills must be of small size.] 
A cross-cut burr drill is a very convenient instrument for 
excavating bone, enlarging fistula, etc. An ordinary gim- 
let may sometimes be used. Dr. Buck also uses a pyra- 
midal borer which is in no danger of suddenly penetrating 
too deeply. (See instrument at the left hand in the figure.) 

The gouge is much used, and is a very good instrument. 
It is usually better to push it in by the pressure of the 
hand than by the use of the hammer, as is the custom with 
many of the continental surgeons. 

Schwartze uses what is called a sharp spoon, an instru- 
ment somewhat resembling a gouge. He also uses a chisel, 
a gouge, and a borer. When the bone is eburnated a ham- 
mer may become necessary to drive the chisel with sufficient 
force. 

Whether using a gouge or drill, it is well to frequently 
pass in a probe or a finger to observe what progress is be- 



Fig. 84. — Stout Knife for Cutting throuch the External Table of the Mastoid. 

ing made. If the lateral sinus has its bony wall chipped 
away, the sensation of a soft body revealed by the finger or 
the touch of the probe will give a hint of this fact, or if the 
meninges have been reached, this test will make us aware 
of the fact. After the external table has been removed, — 
which will vary from one twelfth to one*fifth of an inch in 
thickness, unless it should be associated with osteo-sclero- 
sis, when its thickness may be much greater, — the cells may 
be broken up, if it is thought necessary, by a stout probe or 
steel director. The lips of the wound in the soft parts may 
be kept apart by an assistant using retractors for the pur- 
pose. Dr. Burnett, of Philadelphia, figures in his book on 
the ear a stout knife for opening into the mastoid. I take 
great pleasure in alluding to it, for I am assured that very 
many cases may be operated on by means of this simple 
and effective instrument (Fig. 84). 

Carious spots on the mastoid process may be scraped 
until healthy bone is reached. Buck's instrument, devised 
for this purpose is a good one. Occasionally the lateral 



OPERATIONS ON THE MASTOID. 299 

sinus is opened in the effort to reach the mastoid cells. 
The resulting haemorrhage is much like that from an exten- 
sive phlebotomy, the blood welling out rather excessively. 
A tampon of lint is usually sufficient to arrest it, and it is 
not as serious an accident as one might suppose. It 
only occasionally destroys life. Dr. Knapp recently oper- 
ated on a painful mastoid where there was no tympanal 
complication, in which the cells had undergone a cer- 
tain amount of osteo-sclerosis, with success, but the late- 
ral sinus was opened. The haemorrhage was readily con- 
trolled by a tampon, and no ill results followed. He used 
a narrow chisel and a mallet in the operation. 

Where the mastoid trouble appears at the meatus, or a 
swelling on its posterior wall causes us to suspect complicity 
with the mastoid, it will be proper to open into the cells 
through this region. A drill and a stout probe are the best 
instruments for this purpose. This should be followed by 
washing out the aperture with a syringe having a bent 
nozzle, similar to Schwartze's. Bezold and other authorities, 
however, do not think this plan as effective as opening from 
the outer surface. In the complication described by Bezold, 
where the abscess points at the meatus it certainly would 
be proper to enlarge the opening by appropriate means. 
If the patient is tuberculous or very much reduced it would 
hardly be proper to open the mastoid. Sometimes erysipelas 
supervenes upon an operation on the mastoid ; the whole 
side of the head may be excessively swollen, extending to 
the eye of the same side, so as to close it, and the patient 
have intense fever and be very ill indeed. Where a mastoid 
periostitis recovers and relapses frequently, it is a good rule 
to open the mastoid, as usually some explanation will be 
found for the relapses. In a subsequent section will be 
found a study of the symptoms accompanying fatal cases of 
mastoid and tympanal diseases, where certain points not fully 
developed here will be discussed. 

The after-treatment of operations on the mastoid should be 
conducted for the most part on general principles. Sometimes 
the patient may suffer from the shock of the operation, re- 
quiring anodynes and possibly stimulants. The erysipelas 
occasionally seen may be treated on general surgical prin- 
ciples, being careful to include iron, quinine, and even 
brandy, if necessary for support. If there is much reaction 
the patient should be kept in bed for one or more weeks, 
and occasionally, if there is intense injection of the parts, 



300 DISEASES OF THE EAR. 

iced applications may be cautiously used, as recommended by 
Schwartze. 

The wound should be kept open until suppuration has 
ceased and the patient is well advanced in convalescence. 
A tent may be introduced to keep the wound open, similar 
to that which is done in simple incisions of the mastoid 
process, only being careful to pass the tent into the antrum 
as far as possible. It should remain in from half a day to 
one day, and should be removed whenever signs of confined 
pus appear. I still adhere to my plan of daily passing in 
a probe to break up any adhesions that may have taken 
place in the soft parts, preferring this to the tent for rea- 
sons already given. A drainage tube of soft rubber or sil- 
ver may sometimes act admirably in keeping the wound 
clean. 

Irrigation of the parts should be begun at once, and at 
first practised at least twice a day; afterwards once a day 
may suffice, and as the discharge grows less it may be done 
once in two or three days. Acid, carbolic, three or four grs. 
to the ounce of water, with or without an equal quantity 
of chloride of sodium, is a good injection to use. Any of 
the agents used in an ordinary chronic suppurative otitis 
may be appropriate here; at first mild injections may be 
used, always warm. These should be thrown into the part 
with great gentleness, for fear of causing head symptoms. 
Clark's douche is a good apparatus for this purpose. In- 
ject the Eustachian tube with air frequently. Occasion- 
ally for some reason not immediately apparent no fluid 
will pass from the antrum to the tympanum. After a 
while, however, there is usually no difficulty. If carefully 
done, a probe may be inserted into the open antrum and an 
effort made to cause this to communicate with the tympanum 
should it seem desirable. If at any time during the treat- 
ment the patient should have pain or fever, carefully exam- 
ine the wound to see whether pus is anywhere confined. 
If the soft parts close so as to obstruct free irrigation they 
should be incised. Granulations and polypi often give 
trouble, especially in preventing egress of fluids from the 
tympanum. These may be dealt with as already men- 
tioned in the section on polypi. Schwartze and others use 
drainage tubes both in the antrum and in the mastoid, or 
pass a single tube into* the mastoid, causing it to emerge at 
the meatus; Schwartze recommends the use of a rubber 
tube at first, and when the parts are too much closed then 



AFTER TREATMENT OF OPERATIONS ON MASTOID. 30f 

one made of lead, which should be bent at its outer extrem- 
ity, and fastened by a piece of tape passing around the 
head. 

I do not think it ordinarily necessary to use tubes in the 
mastoid, but they certainly are necessary in the meatus. 
Instead of using a sponge tent for dilatation as recom- 
mended by Schwartze, where the canal is too much nar- 
rowed, I use the rubber tube as directed in the section on 
chronic suppuration of the tympanum. This may also act 
favorably after the manner of a drainage tube. 

The duration of treatment is extremely variable; some will 
recover in a few weeks, while others go on for one or sev- 
eral years. Schwartze states that the average duration of 
treatment in his cases was from nine to ten months. It has 
been thought not amiss to refer to 86 cases of operations on 
the mastoid done by H. Schwartze, of Halle, perhaps the 
best authority now living on this subject. 

(Fro7?i the " Archiv. fiir Ohrenheilkunde" B. 14, S. 202. H. 

Schwartze?) 

" Summary of First Fifty Cases of Surgical Perfor- 
ation of Mastoid Process (Mastoid Bone.) 

Cured 35 cases=7o# 

Not Cured 5 " = io# 

Died 10 " —20% 

Total 50 •' 

By cure, I intend the certain and permanent cessation of 
the purulent processes; but by no means in all cases a func- 
tional and anatomical restitution to a normal condition. Cure 
has resulted after a duration of after treatment from one month 
(case 26) to two years (cases 23, 45, 46). The average dura- 
tion of after treatment is to be estimated at from nine to ten 
months. Of the thirty-five cases which have been put down 
as cured in the above sense, I must except four cases (14, 17, 
3°) 35)) because they did not remain long enough under obser- 
tion to give assurance of a definitive and perfect cure. Of the 
remaining thirty-one cures, twenty-two were chronic cases, and 
nine were acute. The average duration of acute cases was 
from six to seven months; only a single chronic case lasted 
ten months, so that between the two no essential difference 
appears. In the five uncured cases (2, 9, 10, 11, 22), the 



302 DISEASES OF THE EAR. 

grounds of failure in cases 2 and 10 lay in the unsuitable 
method of operation ; in case 9, of total sclerosis of the 
mastoid process, and in cases 11 and 22, in inadeqate 
after treatment. In the fatal cases the causes of death 
were: meningitis (case 1), six weeks after the operation; men- 
ingitis of the convexity (case 19); tubercular meningitis (case 
40), six weeks after the operation ; pyaemia (cases 7, 36). In 
case 7 it was present before the operation ; abscess of the 
cerebellum (case 44), which existed, undoubtedly, at the time 
of the operation ; anaemia (case 50), nine weeks after the oper- 
ation; epithelioma of the temporal bone (case 18); pulmonary 
tuberculosis (cases 4 and 6), six and twelve months after the 
operation. 

" In six of these ten fatal cases death was certainly independ- 
ent of the operative interference (cases 4, 6, 7, 18, 40, 44); in 
three the connection is not certainly proved (cases i, 36, 50); 
and only in one case (19) can the fatal termination be held 
with certainty as the direct consequence of the operation 
(traumatic meningitis of the convexity). Of the doubtful 
cases, case 1 relates to a child of 15 months who died with 
symptoms of meningitis after otitis-media-acuta with forma- 
tion of abscess on the mastoid, (process), some six weeks after 
the perforation of the carious cortex. No post-mortem. The 
probable cause of the fatal issue was in the inadequateness of 
the operative procedure. 

" The small opening which was made with the " grooved " di- 
rector gave no sufficient exit to the pus ; through prolonged re- 
tention of pus there developed purulent meningitis. 

" By means of wider opening of the mastoid, the use of the 
sharp spoon and disinfecting cleansing, death might perhaps 
have been avoided. In case 36, where with total sclerosis of 
the mastoid the canal of the facialis and the external semi- 
circular canal were injured by a faulty use of the drill, the 
decomposition of the thrombus in the lateral sinus was not 
caused by the operation nor by the faulty performance of it, 
but very probably only by the circumstance that notwithstand- 
ing the perforation of the mastoid; on account of the excessive 
stenosis of the auditory canal and the closure of the Eusta- 
chian tube, the retention of pus was not relieved. 

"In case 50, death occurred nine weeks after the operation, 
after the patient had successfully passed through a severe pyae- 
mia, and was already in full convalescence, apparently in con- 
sequence of collapse. No post-mortem. 

" The single instance in which we must regard death as the 



SUMMARY OF SCHWARTZE S CASES. 303 

direct consequence of the operation relates to a case of abnor- 
mal development of the temporal bone, where instead of the 
antrum the middle cranial fossa was opened, and unfortunately 
a splinter of bone perforated the dura mater, causing traumatic 
meningitis of the convexity." 

" From the history of the above cases, the fact appears that it 
is possible by the perforation of the mastoid to bring the most 
difficult and most tedious cases of caries of the temporal bone 
to a perfect and permanent cure, even when the petrosal por- 
tion is involved in the carious destruction; that by this means 
are not only the direct dangers to life definitively removed, 
but that also the indirect consequences to the general condition 
which the bone disease so often induces disappear after the 
operation, provided they are not already too far advanced 
(pulmonary tuberculosis). The patients, who before the oper- 
ation were reduced mentally and physically to a condition of 
chronic invalidism, recover in a few months, even when through 
terrible sufferings lasting many years they had been brought to 
the verge of the grave. [I refer only in this therapeutical re- 
lation to the most remarkable case, (c. 42).] The favorable 
influence of the operation on the cure of a secondary pulmo- 
nary tuberculosis, in cases 5 and 6, is undeniable. In case 5, 
after the cure of the ear difficulty, epilepsy disappeared per- 
manently which had lasted for ten years. Facial paralysis dis- 
appeared two days after the operation in Case 33, and in the 
third week after the operation in Case 30; on the contrary it re- 
mained unchanged in Case 4, in which six months after the oper- 
ation death occurred from pulmonary tuberculosis, In regard 
to the hearing in the 31 cases of cure, it may be mentioned 
that eight times (cases 3, 5, 13, si, 25, 27, 29, 39) it became 
perfectly normal ; in the remaining cases, as far as we have re- 
liable data, the hearing distance for the watch ranged from 2 to 
34 cm. (2 m. normal). In only one case was contact of the 
watch with the auricle requisite. This difference depends, as 
we may readily understand, on the extent and location of the 
derangements in the sound-conducting apparatus caused by 
disease before the operation. In 11 cases (3, 5, 13, 15, 21,24, 
25, 27, 28, 39, 43) cicatrization of the perforations of the drum- 
membrane was observed. In the four cases (33, 34, 4 2 > 45) in 
which after perfect cure of the caries absolute deafness re- 
mained, it was to be assumed, from the results of the tuning- 
fork applied to the cervix before and after the operation, that 
the carious process had already attacked the bony labyrinth. 
In case 33 there was positive proof for this assumption in the 



304 DISEASES OF THE EAR. 

necrosed and extruded cochlea; in case 45, where the disease 
affected both sides, there was proof in the deaf-mutism. 
"As regards age in the fifty cases, there were 

From 1 to 10 years 12 cases. 

" 11 to 20 " 16 " 

" 21 to 30 " 13 " 

" 31 to 40 " 1 case. 

" 41 to 50 " 3 cases. 

Over 50 " 5 " 

The youngest patients were in the second year (cases 1, 32, 
40) ; the oldest 78 years. 

"Second series of fifty cases of surgical perforation of mastoid" 
(Casuistic zur chirurgischen Eroffnung des Warzenfortsatzes). 
H. Schwartze, zweite serie Archiv. fur Ohrenheilkunde. B. 
XVI., XVII., XVIII., being a brief statement of the salient 
points of each case. 

"Case 51. Otitis media purulenta chronica wuth abscess on 
the mastoid and fistula. Dilatation of the osseous fistula with 
the gouge and hammer. Scraping the mastoid antrum. Cure 
in ten months. 

"Case 52. Otitis media purulenta chronica with abscess on 
the mastoid. Perforation of the mastoid with grooved direc- 
tor (Hohlsonde). Permanent cure in nine months. 

"Case 53. Otitis media purulenta acuta with abscess on the 
mastoid. Dilatation of an osseous fistula with the grooved di- 
rector. Death in eight days of miliary tuberculosis. 

" Case 54. Otitis media purulenta chronica after scarlet fever. 
Sinus-phlebitis. Metastatic pyaemia. Opening of the antrum 
with the gouge. Death. 

" Case 55. Chronic suppurative process of middle ear with fis- 
tulous opening into the meatus and inflammation of the mas- 
toid. Opening the antrum with the chisel. Cure in two 
months. 

" Case 56. Chronic suppurative process of middle ear. Fis- 
tulous opening in the cortex of mastoid. Cutaneous covering 
unchanged. Dilatation with gouge. Drainage. Cure in 
twenty-one months. 

" Case 57. Development of acute abscess in the mastoid cells 
without perforation of the drum membrane. Opening of the 
mastoid with the chisel. Cure in seven weeks. 

" Case 58. Central caries of mastoid with fistula into meatus. 
Opening the mastoid with chisel. Cure in fifteen months. 

"Case 59. Periostitis syphilitica chronica. Opening of mas- 
toid with the chisel. No escape of pus. Cure in nine weeks. 



schwartze's cases of mastoid disease. 305 

"Case 60. Otitis media purulenta acuta with secondary peri- 
ostitis and fistulous opening through the cortex of the mastoid. 
Multiple polypi in auditory canal. Opening of mastoid with 
the chisel. Cure in three months. 

"Case 61. Chronic purulent disease of middle ear, lasting 
four years. Repeated abscesses on the mastoid. Fistula in the 
cortex. Dilatation. Scraping out the antrum with the sharp 
spoon. Cure after two years. 

"Case 62. Otitis media purulenta acuta with abscess on mas- 
toid. Minute fistulous opening in the cortex. Dilated with 
gouge. Cure in three weeks. 

" Case 63. Chronic purulent disease of middle ear with polypi 
and facial paralysis. Opening the mastoid with gouge. Sub- 
periosteal abscess of the mastoid abscess on the carious pet- 
rous portion beneath the dura mater. Death from meningitis. 

" Case 64. Otitis media purulenta acuta with implication of 
the mastoid. Repeated incisions. Perforation with chisel. 
Cure in nine months. 

" Case 65. Otitis media purulenta acuta with involvement of 
the mastoid. Antrum opened with chisel. Cure in three 
months. 

"Case 66. Scrofulous caries of mastoid. Antrum opened 
with the chisel. Cure in one year. 

"Case 67. Otitis media purulenta chronica. Purulent peri- 
ostitis with superficial caries of the mastoid. Scraping. Cure 
after four weeks. 

" Case 68. Otitis media purulenta chronica with abscess and 
fistula into the auditory canal. Antrum opened with chisel. 
Cure in six weeks. 

" Case 69. Otitis media purulenta chronica. Fistula in mas- 
toid. Dilatation with chisel. Antrum filled with cholesteato- 
mata. Masses cleared out by means of the sharp spoon. Cure 
in nine months with cicatrized fistula in the bone. 

" Case 70. Caries necrotica with fistulous perforation of the 
mastoid. Scraped out with sharp spoon in 1869. Apparent 
cure. Relapse after eight years with facial paralysis and cere- 
bral symptoms. Mastoid opened with chisel. Death from 
meningitis purulenta diffusa after twenty-two days, in conse- 
quence of necrosis of the labyrinth. 

"Case 71. Otitis media purulenta chronica. Fistula in mas- 
toid. Dilatation with chisel. Scraping out the mastoid and 
auditory canal with sharp spoon. Cure in eight months. 

" Case 72. Otitis media purulenta chronica. Secondary peri- 
ostitis of mastoid. Carious opening through cortex. Chiselling 



306 DISEASES OF THE EAR. 

and scraping out the antrum. Drainage. Permanent cure in 
two months. 

"Case 73. Otitis media purulenta acuta with empyema of 
mastoid. Antrum opened with chisel. Cure in five weeks. 

" Case 74. Otitis media purulenta chronica with necrosis of 
mastoid. Extraction of sequestrum. Dura mater laid bare. 
Cure. Death after thirteen months from pulmonary tubercu- 
losis — long after the wound from the operation had healed. 

" Case 75. Otitis media purulent aacuta with neucrotic caries 
of mastoid. Extraction of sequestrum. Dilatation of fistula. 
Death four weeks after of catarrhal pneumonia. 

" Case 76. Otitis media purulenta chronica with necrotic ca- 
ries of mastoid. Sharp spoon. Death in twenty-four days 
of tubercular meningitis. 

" Case 77. Otitis media purulenta chronica duplex with caries 
of left mastoid of ten years' duration. Opening the antrum 
with chisel. Scraping. Drainage. Cure in two years. 

"Case 78. Otitis media purulenta chronica. Fistula. Se- 
questrum of cortex removed. Dilatation of fistula with chiseL 
Removal of granulations with sharp spoon. Drainage. Cure 
in two years. 

"Case 79. Otitis media purulenta chronica for seventeen 
years. Sudden symptoms of brain irritation and chills. Dis- 
turbance of speech. Subperiosteal abscess on the mastoid. 
Fistulous opening in cortex. Dilatation and drainage. Death 
eight days after the operation, of abscess cf brain, with menin- 
gitis purulenta (?). No post-mortem. 

"Case 80. Otitis media purulenta chronica with abscess as 
large as one's fist, behind the ear, and fistula leading to an- 
trum. Dilatation of fistula. Drainage. Death next day. No 
post-mortem. 

" Case 81. Otitis media purulenta chronica of 12 years' stand- 
ing with central caries of mastoid. The sound outer wall chis- 
elled through and a fistulous canal kept open. Cure in one 
year. 

" Case 82. Otitis media purulenta chronic aafter pneumonia. 
Abscess above and behind the ear and burrowing into the 
lateral and posterior regions of neck. Secondary superficial 
caries of occiput. Opening antrum with chisel. Cure in four 
months. 

" Case 83. Otitis media purulenta chronica with necrotic 
caries of mastoid operation. Cure in a year and a quarter. 

" Case 84. Chronic periostitis with sclerosis of mastoid and 
widely extending firm-walled fistulous passages leading to the 



schwartze's cases of mastoid disease. 307 

lateral and posterior regions of the neck. Cure in two and a 
half months. 

" Case 85. Otitis media purulenta chronica lasting four 
months. Necrotic caries of mastoid. Use of chisel and sharp 
spoon. Cure in four weeks. 

" Case 86. Otitis media purulenta chronica duplex and sec- 
ondary periosteal abscess over the right mastoid. Fistulous 
opening in cortex. Dilatation with chisel. Sharp spoon; 
Drainage. Death in four weeks of purulent meningitis." 



UNCLASSIFIED DISEASES. 

SOME CONSIDERATIONS REGARDING FATAL CASES OF SUPPURA- 
TIVE OTITIS WITH OR WITHOUT MASTOID COMPLICATIONS. 

Fatal complications arise — 

From the disease extending to the brain, causing in- 
flammation of the meninges, brain substance, blood-ves- 
sels, and sinuses. 

Purulent inflammation of the mastoid cells, where the mas- 
toid ruptures at the inferior portion, at or near the digas- 
tric fossa, or in the outer part of the osseous meatus, caus- 
ing the pus to burrow beneath the muscles of the neck, 
may result fatally from the exhaustion incident to the puru- 
lent process. 

Inflammation may extend from the ear to the brain when- 
ever any of the bony partitions which separate the tym- 
panum, the mastoid cells, or the labyrinth from the brain 
become necrotic or carious, or when these bony partitions 
become perforated from inflammatory processes; carious 
processes in the meatus sometimes extend to the brain. 
Inflammation may extend to the brain from the ear by 
continuity, there being a free interchange between the 
ear and the brain by means of numerous vessels, nerves, 
foramina, etc. If the oval or round window be destroyed 
by ulceration, there is then essentially a continuous open- 
ing into the brain through the continuity of the peri- 
lymph and subarachnoid spaces. Septic material may be 
carried from the ear to the brain by means of blood-vessels, 
causing abscess of the brain-substance, phlebitis, thrombosis, 
etc. 

Necrosis and caries are the direct results of inflamma- 
tion ; the former being rather the consequence of inter- 



308 DISEASES OF THE EAR. 

rupted nutrition from disturbances in the blood supply 
during the inflammatory process; the latter is the result of 
a true ostitis communicated from the soft parts, which re- 
sults in ulceration, a breaking down and exfoliation of the 
bone as sequestra. Both of these are more likely to occur 
in the strumous and the syphilitic, but still more likely in 
infants and young children. Pus confined in any cavity 
may attack the bone, especially if there is considerable 
pressure. On the other hand, any part or the whole of the 
temporal bone may be removed by carious processes with- 
out destroying life. My own case of John Eddington, 
recorded under the heading of mastoid diseases, fully illus- 
trates this. Numerous other cases of a similar nature to 
be found in literature abundantly prove that life is not 
necessarily lost by destruction of the temporal bone by 
caries. The meninges, it is true, are laid bare, but it is 
probable that the inflammatory process has so thickened 
them as to cause them to be a sufficient protection to the 
brain from the inflammatory processes. I am inclined to 
the opinion that children bear a greater amount of bone 
exfoliation from ear disease than adults. Abscess of the 
brain is thought by some of the best authorities to be 
caused by ear affections in from one half to two thirds of 
the cases, it never being a primary affection. There may 
be no diseased tissue between the abscess situated deeply 
in the cerebral substance and the diseased ear, but which 
may, nevertheless, have depended on the ear for its cause. 
The explanation of this is not easy. Abscess of the rectum 
may cause a cerebral abscess, although the latter is rarely 
metastatic; a brain abscess, as has been observed by the 
late E. H. Clarke, M.D., of Boston, and Geo. P. Field, of 
Glasgow, and others, sometimes gives no notice of its pres- 
ence by disturbance of function. If, however, it approaches 
the surface, a meningitis is excited which rapidly destroys 
life. The abscess is usually situated in the posterior part 
of the brain and is generally single. Its remoteness from 
the motor tract will explain why paralysis is so infrequent. 
According to Mr. Field in the London Lancet, June 5, 
1880, an abscess of the brain sometimes remains for years 
unsuspected, and the patient may die of some other dis- 
ease; the pus- cells undergoing fatty and granular degen- 
eration, and all that remains of the abscess may be a fibroid 
sac, containing chalky material, the fluid portions having 
been absorbed. 



CONSIDERATIONS REGARDING FATAL CASES. 309 

The tendency of the disease to extend to the brain is in- 
creased whenever, from any cause, products of inflamma- 
tion fail to find a free outlet. This may occur in tympanal 
affections where the membrana stoutly resists perforation, 
and matter is confined in the tympanum. Polypi and 
granulations may so crowd the tympanum and meatus as 
to prevent egress of inflammatory products. Impacted 
cerumen sometimes acts very obstructively. Bony, growths 
in the meatus, or even occlusion from other causes, may so 
act. Foreign bodies in the meatus or tympanum may pro- 
duce similar results. The roof of the tympanum is exceed- 
ingly thin, and it is sometimes found partially wanting, 
which naturally offers a feeble resistance to destructive 
processes. The inner and upper wall of the mastoid 
antrum is thin, lies in apposition with the lateral sinus, and 
offers much less resistance to the invasion of disease than 
the outer or cortical portion of the mastoid cells. The lat- 
ter also is frequently much thickened by osteo-sclerosis, 
making it quite impervious to disintegrating inflammatory 
action, which, if destroyed by caries, might allow escape of 
the purulent material. 

The ear affections which destroy life are, as a rule, 
chronic, or a new inflammation is lighted up on an old pro- 
cess. A few exceptions to this rule, however, occur. The 
following case may illustrate an exception. It is reported 
by G. S. Ryerson, M.D., etc., in the Canada Laiicet, Nov., 
1881. The patient was a child who was comatose when 
first seen; ptosis of right eyelid, divergent squint, and dila- 
tation of both pupils occurred; recovering from scarlatina. 
Had been screaming with pain in the left ear for some 
days; membrana tympani bulging; was incised, and bloody 
serum escaped, giving relief. April 5th, five days later, a 
purulent process was inaugurated; pains in the arms and 
legs. On April 8th, pain and tenderness in the mastoid, 
pain in the head; mastoid trephined and a brownish gru- 
mous fluid escaped; periosteum detached and discolored; 
this gave great relief. Next day very little ptosis, all the 
symptoms relieved except profuse and offensive discharge; 
no fever. 

April 10th, could not see well; pupils dilated but moder- 
ately movable; optic disks swollen, with enlarged and tor- 
tuous arteries and veins. A small abscess of the arm and 
one of the auricle was opened. April 12th, screamed with 



3IO DISEASES OF THE EAR. 

pain all the time; discharge less; fever and delirium. On 
April 21st severe rigors developed and the child died. 

Post-Mortem. — Dura mater thickened and adherent to 
calvarium. On division, much serum escaped; brain con- 
gested, more on left hemisphere; ventricles full of serum; 
degenerated pus beneath the pia mater over each superior 
lobe; lateral sinus full of blood clots and pus; caries of roof 
of tympanum; dura mater extensively detached, beneath 
which was considerable pus. 

The case was remarkable as being an abscess of the 
brain following acute inflammation of the ear, and for its 
remoteness from the organ. Toynbee reported only one 
case of abscess of the brain consequent on acute inflamma- 
tion of the ear. In this instance, the pus was carried by 
the veins, as there were symptoms of pyaemia. (Am. Jour. 
Otol., '82, No. I., p. 75, signed G. B.) 

Some of the more Frequent Symptoms observed in Fatal Cases 
of Ear Disease. — True brain symptoms in cases which result 
fatally are not certainly diagnosticated from the signs of 
brain irritation found in many cases which recover. It 
will always, perhaps, be a vexed question whether a pa- 
tient with any considerable brain disease has ever recov- 
ered. Certain minor brain troubles have, without doubt, 
terminated favorably. Brain symptoms where paralysis is 
included, usually point to fatal brain lesions. With few ex- 
ceptions, the trouble that terminates in death is engrafted 
on an old case, and appears as an acute exacerbation, which 
may repeatedly be relieved, but recurs from time to time, 
and terminates only in death. 

One symptom, which is the most important of all, is pain ; 
this may be in any part of the ear or head, and often is of 
the most excruciating character, defying all known means 
of relief, except, perhaps, the temporary palliation afforded 
by ether or chloroform. Its location, in the ear or head, is 
by no means a certain indication of the exact situation of 
the lesion. 

When the neck is involved in burrowing abscesses, the 
pain will be more likely to be in that neighborhood, and in 
that part of the spine adjacent to the swelling. 

Pain may occur in the most remote parts: the legs and 
arms or the chest; these facts are not so easy of explana- 
tion. Exacerbations of the pain are more likely to occur 
at night; the haggard and emaciated appearance of the pa- 
tient gives evidence of the gravity of the disease. 



SYMPTOMS IN FATAL CASES OF OTITIS. 311 

Fever nearly always accompanies these processes, al- 
though there may be many remissions, especially in the 
earlier and later developments of the disease. This will 
often simulate an intermittent form, and large doses of 
quinine will frequently be beneficial. 

The temperature in the earlier period of the progress of a 
case may not be elevated, but later on it is very likely to 
be; it varies, some days being normal, and others elevated. 
At the last it may be below the normal. 

The pulse is a valuable indication. At the outset it may 
not. be changed in character, but subsequently it may be- 
come very rapid. It is not likely to be of the full, bound- 
ing variety, but occasionally it is. In the later stages it 
may be weak and threadlike. If there is much pressure 
upon the brain and medulla oblongata, it may be intermit- 
tent, slow, and perhaps dicrotic. The peculiar pulse of 
extreme exhaustion may be often observed. The tempera- 
ture of the body is not usually greatly elevated as in some 
sthenic forms of fever, although it occasionally is. 

A profuse perspiration is often an important symptom, 
and later on, the cold, clammy perspiration of complete ex- 
haustion may be present. The tongue may show no marked 
signs of disease in many instances, while in others it may 
exhibit the usual signs of fever (dry, rough, coated, etc.). 
We are constantly confronted by contradictory symptoms. 

The bowels in only a few instances show the marked con- 
stipation characteristic of brain disease, and only occasion- 
ally the involuntary evacuations of the last stages of brain 
trouble are observed. 

The intelligence is often most remarkable, and depends on 
the fact that only certain parts of the brain, usually those 
located posteriorly, are involved in the disease. Sluggish- 
ness of the intellect is occasionally seen, with inability to 
articulate certain words. Most of the cases end with com- 
atose symptoms. 

Delirium is not uncommon, especially among children. 
Convulsions are not infrequent, and are sometimes accom- 
panied by opisthotonos. Sleeplessness is an important 
symptom. Rigors are a valuable symptom, showing the 
pernicious action of confined, and possibly absorbed pus 
upon the system. Dizziness or vertigo, when persistent, is a 
bad symptom, the patient being inclined to fall in a direc- 
tion opposite to the affected ear. 

Nausea and vomiting are always bad symptoms, especially 
20 



312 DISEASES OF THE EAR. 

if they recur from time to time. Where a patient has previ- 
ously heard a tuning fork by conduction in the affected ear, 
and subsequently fails to hear it, there is evidence that the 
disease has reached the labyrinth or the brain. Paralysis 
is an important symptom, especially that of any of the 
nerves passing near the lateral sinus, this being accom- 
panied by ptosis, divergent squint, dilated pupil, etc; intra- 
cranial trouble may then be strongly suspected, and in- 
deed, almost proven. 

If the medulla oblongata becomes involved, paralysis of 
the hypoglossus ensues, when, upon the patient making an 
attempt to show the tongue, it will protrude towards the 
paralyzed side. The arm opposite to the affected ear, or 
even the whole side, may become paralyzed, or in extreme 
disorganization of the brain general paralysis may ensue. 
Any disturbance in the functions of the pneumogastric nerve 
is an unfavorable symptom. 

Tinnitus aurium coming on suddenly in an acute exacer- 
bation is sometimes a noticeable symptom. A sudden ar- 
rest of the discharge, in a chronic case, with febrile symp- 
toms, often precedes a fatal issue, although in itself consid- 
ered, it may not be of grave moment. I can give no special 
reason for the following observation, but in looking over an 
extended record of fatal cases, it appears that those who 
have a considerable swelling below and in front of the mea- 
tus, frequently do badly; herpetic eruptions about the face 
and neck are often observed in the grave cases; so also is 
exophthalmos with redness and swelling of the eyelids. 

Some of the more important post-mortem appearances are as 
follows: Mucous lining of the tympanum swollen, infiltra- 
ted, and congested; tympanum filled with polypoid mate- 
rial or malignant growths or cheesy tuberculous material 
with or without epithelial masses; cholesteatomata or mu- 
cus, pus, blood, serum, etc., may fill the tympanum; there 
may be total absence of mucous lining of the cavum with 
necrotic discoloration of the bony wall. Ossicula all pre- 
sent, if membrane is intact, but the ligaments may be partly 
destroyed by ulceration, or may be found sclerosed. In other 
instances, membrana and ossicles may be swept away, leav- 
ing, however, for the most part, the base of the stapes, which 
resists very strongly destructive processes. The chorda 
tympani nerve is frequently destroyed by ulceration. 

The mastoid cells are sometimes found completely closed 
by a hyperostotic process, and converted into a bony ma- 



POST-MORTEM APPEARANCES. 3 13 

terial of ivory-like hardness. The process of suppuration 
may have swept away all the cell divisions, leaving one 
vast cavity in the mastoid process, which may open by 
a large aperture into the tympanum. It may be exten- 
sively infiltrated with pus and other inflammatory products 
or completely filled with polypoid material. Fistulous 
openings may often be noticed in the mastoid process, 
usually communicating with the antrum, but occasionally 
found in the lower and inner portion of the mastoid pro- 
cess, and sometimes communicatingwith the meatus; where 
the perforation of the mastoid is in the digastric fossa, the 
burrowing abscesses may cause the bones of some of the 
cervical vertebrae to be attacked by caries. The roof of 
the tympanum is frequently perforated by carious pro- 
cesses, or it may be thickened, and the region in juxta- 
position to the inner wall of the mastoid cells may be 
destroyed, resulting in an opening into the lateral sinus. 
Occasionally the thin anterior wall of the tympanum may 
present a carious opening, communicating with the carotid 
artery, when sudden death from haemorrhage is likely to 
result. Occasionally the whole of the temporal bone is 
destroyed by caries, and an immense cavity formed, which 
maybe filled with foetid purulent material. This condition 
is more likely to result from malignant disease. The 
vestibule, semicircular canals and cochlea are sometimes 
filled with a red, solid, flesh-like granular mass, which pro- 
jects into the aqueductus vestibuli and the internal audi- 
tory meatus. This material is composed of a net-work of 
connective tissue fibres interspersed with round cells. In 
the meshes of this stroma, larger cells have been found. 
Fat granules and epithelial cells have been found in the 
vestibule. The Eustachian tube sometimes has its calibre 
much widened by destructive ulcerative processes, or it 
may be blocked up with inflammatory products. 

The dura mater may be hyperaemic, more especially that 
portion in the vicinity of the diseased ear. The veins may 
be much injected, and some of the vessels embolic. It may 
be thickened and abnormally adherent to the calvarium. 
It may also be detached from the bone (in the petrous 
portion it is normally adherent), discolored, and with pus 
formations beneath it. Sometimes it is found in a state of 
pachymeningitis. Growths on the dura near the petrous 
portion have been observed. There may be a purulent 
meningitis, with or without sloughing of the meninges. 



3 H DISEASES OF THE EAR. 

Foci of inflammation may sometimes be seen, and in a 
single instance, one of these was found at the lobulus of the 
pneumogastric nerve. Sometimes the dura is adherent to 
the arachnoid. In one case, the dura over the orifice of the 
aqueductus vestibuli, on the posterior part of the petrous 
bone, was bulging with pus which had reached this point 
from the vestibule, and the auditory nerve was in some 
places discolored, and in others disorganized by the puru- 
lent process. 

The pia mater sometimes shows injected veins with other 
signs of hyperemia. It may be infiltrated with serum; pus 
is occasionally found beneath it. It maybe adherent to the 
gray substance of the brain. 

The Arachnoid. — Pseudo-membranous deposits are some- 
times found upon the arachnoid, while in others it may be 
in a state of purulent infiltration, or swollen with oedema. 

The cerebral lobes, as well as those of the cerebellum, may 
be more or less intensely congested. Where considerable 
intra-cranial pressure has existed, the convolutions of the 
brain may be compressed and flattened. Sometimes the 
surface of the arachnoid will be covered by a puriform 
lymph. 

Abscesses are found in the brain substance usually at or 
near the middle or posterior part, and may be some dis- 
tance from the surface. The ventricles may be broken up 
by an invading abscess. The contents of these abscesses 
may be of the greatest possible variety, from normal, not 
ill smelling pus, to the most foetid and degenerated puru- 
lent material. Haemorrhagic spots are sometimes observed 
in the gray substance. In other instances, the brain ap- 
pears " pale, flabby, and diffluent," from degenerative 
changes. Collections of pus are sometimes seen along 
the walls of the vessels of the convexity. In extensive 
disease of the brain, blood-vessels are often obliterated. 
The vertebral arteries have been found wanting. The 
ventricles, more especially the lateral, often contain an ex- 
cess of serum, which may be clear, or rendered turbid by 
grayish red flocculent material. Sometimes they are filled 
with pus, which may have broken down their walls. The 
septum lucidum may be destroyed by purulent processes. 
The membrane of the pons varolii has been found covered 
with a greenish deposit, and the substance broken down 
nearly to the walls of the fourth ventricle. 

The sinuses are very frequently attacked, notably the 



POST-MORTEM APPEARANCES. 3 J 5 

lateral, which is in such close proximity to the antrum of 
the mastoid. Occasionally the petrosal and transverse 
sinuses may be involved. In rare instances the superior 
longitudinal sinus may be attacked. The sinuses may be 
covered by a tenacious thick deposit on their walls, or 
bathed in masses of pus. In their interior may be found 
coagula, or fluid-blood, or pus. Thrombi are perhaps more 
frequently seen adhering to their walls. The greenish red 
thrombi are more recent, and the yellowish, gray, or black 
are of greater age. 

These may break down into a puriform material. The 
walls of the sinuses may be found destroyed by suppurat- 
ive processes of the dura mater, and obliterated, their site 
being occupied by a reddish, fleshy granular material, rep- 
resenting the ordinary products of inflammatory prolif- 
eration. 

The jugular vein sometimes contains clots, which after a 
time become dense, firm, granular, and of a brown color. 
It is also found to exhibit similar changes to those seen in the 
sinuses. 

The carotid has been found infiltrated with purulent exuda- 
tions. Both jugular vein and carotid artery have exhibited 
thickening of their walls. Metastatic abscesses have been 
found in the spleen, kidneys, liver, lungs, etc., dependent on 
the brain disease. Pleurisy, with effusion of serum and pus, 
has been noted as secondary to abscesses of the brain. Peri- 
tonitis with submucous ecchymoses in the intestines has been 
observed in autopsies of fatal ear cases. In very rare instances 
the upper wall of the meatus and the roof of the tympanum 
have become carious, and involved the brain, without attack- 
ing the tympanum at all. Dr. J. O. Green reports such a case 
in " The Tr. Am. Otol. Society " for 187 1, p. 70. 

In the report of the first congress of the International Oto- 
logical Society, held in New York, September, 1876, I reported 
a case of abscess over the mastoid region, extending to the 
squamous portion and involving the meninges and brain sub- 
stance without attacking the tympanum. 

[The above facts have been gleaned from a considerable 
number of recorded autopsies.] 



316 DISEASES OF THE EAR- 



MALIGNANT DISEASE IN AND ABOUT THE EAR. 

I am thus indefinite in this designation, because in a 
large number of cases it is impossible to determine the 
exact point from which a given tumor springs. It is known 
that the meatus auditorious externus may be the starting 
point of a malignant growth; at the internal auditory 
meatus, on the sheath of the auditory nerve, or on the dura 
mater lining the meatus, is a favorite seat for these tumors. 
Virchow has stated that the acoustic nerve is more likely to 
take on malignant disease than any other cranial nerve. As 
a rule, the fibrous sheath of this nerve is attacked, but one 
case, herewith recorded, shows that the fibres of the nerve 
itself may become involved in the disease. Other cranial 
nerves also become affected, notably those in the vicinity 
of the Gasserian ganglion. Some of the cases herewith 
recorded show the tumor to have arisen from the mucous 
lining of the tympanum. Moos states that the submucosa 
of the tympanum was the starting point of a malignant 
tumor he reported. The variety of tumor usually found, 
is for the most part that denominated sarcoma, with the 
subdivisions of Fibro-Sarcoma, Melano-Sarcoma, Os- 
teo-Sarcoma, Myxo-Sarcoma, Round-celled Sarcoma, Spin- 
dle-celled Sarcoma, Chondro-Sarcoma, Glyoma or Glyo- 
Sarcoma, and occasionally a Chondro-adenoma, with a few 
cases of Epithelioma of the meatus or middle ear, and occa- 
sionally carcinoma of the acousticus may be found. 

The appearances on inspection of malignant growths in this 
region are as follows: In the meatus or tympanum they 
are likely to be darker colored than other growths, although 
their appearance is not diagnostic. They bleed more pro- 
fusely than benign growths and are more painful ; the 
discharge is likely to be very offensive, and the tumor in- 
variably reappears after removal — sometimes as soon as 
one or two days. They are likely to extend to the mastoid 
region and to involve the post and pre-auricular glands 
which may result in abscesses. These often have a dark 
color and a more or less boggy feel. 

A fungous appearance of any tumor about the ear casts 
suspicion on its benignity. The variety of tumor which is 
most malignant has the appearance of a mucous or a ge- 
latinous polypus. Before the tumor has made its appearance 
externally, its presence may be suspected by paralysis of 



MALIGNANT DISEASE OF THE EAR. Z l 7 

certain muscles, the nervous supply of which has been in- 
terrupted by the tumor. For instance, it is not uncommon 
to see a paralysis of nerves from the 3d to the 8th or 
9th, with the exception generally of the 4th. As a conse- 
quence there will be strabismus with ptosis, or the eye may 
remain in the centre of the palpebral fissure when the 3d 
and 6th -nerves are paralyzed. 

Deglutition is often interfered with in consequence of the 
paralysis , sometimes making it well-nigh impossible for 
the patient to swallow food ; in other cases the food may 
fall into the larnyx or pass out through the nostrils. The 
invasion of the pharynx by an aural tumor may also pro- 
duce the same . result. Paralysis of most or all of the 
branches of the facial is not uncommon. 

Ataxic movements of the arms and legs are frequently 
seen, more especially, however, of those on the diseased 
side. Faulty co-ordination is sometimes observed in walk- 
ing. Epileptic attacks are not infrequent, as well as other 
forms of convulsions. The optic nerve is sometimes in- 
flamed or simply hyperaemic, or in a state known as choked 
disk. When the tumor has approached the region of the 
eye, there is likely to be exophthalmos with occasionally an 
injected eyeball. The vision is not often lowered; the pupil 
may be dilated or contracted. Anaesthesia of the side of the 
face is sometimes seen. In a few instances a neuro-paralytic 
inflammation of the cornea with occasional destruction of 
that tissue is observed; spasm of muscles of the eyeball pre- 
vious to becoming paralyzed has been noticed. The pulse 
is frequently elevated, but not always. The respiration is 
sometimes quite frequent but by no means always so; the 
temperature is not often elevated, and sometimes in the 
later stages it may be even lowered. Towards the termina- 
tion of the disease, sordes may be seen on the lips, gums and 
teeth, and the patient is likely to pick at the mouth and nose. 
There is occasionally an ichorous discharge from the nostrils. 
In the soft varieties of sarcoma, the tumor may slough to 
a considerable extent, but will soon reproduce itself. In 
autopsies, the dura mater is infrequently found to be pene- 
trated by the tumor, though it may be thinned by the 
pressure exerted upon it by the growth. The malignant 
quality of the tumor is often very slight at its commence- 
ment, but it seems to be aggravated in proportion as efforts 
are made to remove it. Occasionally the tumors seem en- 
tirely innocuous at the commencement. 



318 DISEASES OF THE EAR. 

The subjective symptoms are of great variety. In some of 
the worst cases, very few symptoms may be observed. A 
tumor may press on the brain, with apparently no func- 
tional disturbance. The intellect is almost always clear 
until the latter stage of the affection, and in some cases to 
the very last. There is a variable amount of pain in the 
head, ear and throat, but this symptom has no great signifi- 
cance. The patient is sometimes irritable, loses appetite, 
and does not always sleep well. Vertigo, nausea, vomiting, 
rigors, delirium and coma are frequently seen towards the 
termination. The affection is more frequent in women than 
men, and in children than in adults. 

The duration of malignant disease about the ear is exceedingly 
variable. In some cases the patient has lived six or seven 
years. In others a few weeks has been sufficient for a fatal 
termination. The duration seems to depend on the degree 
of malignancy and possibly on the amount of operative in- 
terference to which the tumor is subjected. The causes are 
often difficult to determine. Heredity is by no means a 
constant factor in developing the affection. Syphilis some- 
times seems to have caused it. Traumatism occasionally 
appears to be the starting point of the growths, but a sus- 
picion will creep in that a predisposition to the disease al- 
ready existed, which was called into activity by the injury. 
The same remark applies to the influence of cold in develop- 
ing the affection. 

Sex evidently has something to do with the causation of 
the disease, women being more subject to it than men. 
The results of the disease are sufficiently exhibited in the ac- 
companying cases. I do not remember to have heard of a 
case which terminated favorably, unless it were a mitigated 
form of epithelioma. 

The treatment is sufficiently detailed in the cases hereafter 
reported. If a high degree of malignancy is discovered by 
the microscopic examination, a judicious surgeon will re- 
frain from operating. Similar affections confined to the 
interior of the eye may be arrested by enucleating; but 
about the ear there seems no means of drawing so distinct 
a line between the diseased and healthy tissues. Symptoms 
must be treated as they arise, on general surgical principles, 
a prominent indication being to render the patient as com- 
fortable and free from pain as possible. 

A brief statement of the case reported by me in the Am. 
Jour. Otol., April, 1881, is as follows: A girl six years of age 



A CASE OF MALIGNANT DISEASE OF THE EAR. 319 

applied to me on April 17th, 1880, on account of a converg- 
ent squint in the left eye which had existed for ten weeks. 
External rectus of the left eye completely paralyzed and 
internus in a state of spasm, drawing the eye sharply in- 
ward. Hearing of right ear, for the watch, 24 inches; of 
the left, watch in contact with the auricle. In the right are 
symptoms of middle ear catarrh. The left shows a minute 
granulation protruding through a perforated membrane. 
Tuning fork heard best in the left ear. Pulse and tempera- 
ture normal. After a consultation, the diagnosis was be- 
tween basilar meningitis and malaria. Quinia was first 
administered; afterwards large doses of pot. iodid. Fara- 
dism was used on the affected muscle. The granulation 
was removed by forceps. 

After the first week there was pain in the left eye and 
ear, darting towards the throat. Iodine to the temple, a 
blister to the mastoid and atropine in the eye relieved the 
pain for a time. Patient is too quiet, sleeps too much, but a 
paroxysm of pain readily arouses her; bowels constipated. 
In eight or nine days complete paralysis of the motor oculi 
occurred and the eye remained in the centre of the palpebral 
fissure, with a drooping lid. Pulse occasionally rose to 130, 
but the temperature was normal. The pain soon returned 
and was not relieved by an opiate; patient very irritable. 
Optic nerve decidedly hyperaemic. On May 26th there was 
a little twitching of hands and feet, more noticeable in the 
left. On the 27th the pulse ranged from 130 to 84; will 
cry out if the eye is touched, although it is not reddened. 

Mouth drawn to the right side, and she talks a little 
" thick." Tongue protruded towards the left. Respira- 
tion about keeps pace with the temperature. Mind clear 
and always has been. Sometimes she behaves quite natu- 
rally. Not inclined to take nourishment unless urged. May 
31st, darkish coating on lips and gums; picks her mouth 
and nose. 

June 1st. Return of pain in the eye, and there is an 
offensive discharge from the ear; found a soft, gelatinous 
mass filling the meatus; removed it by forceps, and some 
haemorrhage resulted. 

June 2d. Nausea; lid did not droop as much on account 
of paralysis of orbicularis. 

Being somewhat better, she was sent to her home in the 
country. Carbolic acid solution was used in the ear; 
iodide of potass, continued with attention to the nutrition. 



3 20 



DISEASES OF THE EAR. 



It was now believed that all the symptoms depended on a 
malignant growth in the tympanum or its neighborhood. 
After a few weeks, the ear again filled with a material simi- 
lar to that which had been removed, This was followed 
soon after by a tumor just behind the lobulus and another 
beneath the tragus. 

These tumors grew with alarming rapidity, and on her 
return to town on Aug. 15th they had extended down the 
neck for nearly five inches (Fig. 85). The tumor was here 




Fig. S>. — Extra- cranial Portion of the Tumor Reported on Page 503. 

and there bloody, with spots which had undergone decom- 
position, and it being warm weather, flies were constantly 
alighting on it, rendering the patient restive: it was very 
offensive. The patient was taken home. After a time, de- 
glutition became difficult on account of the paralysis. There 
was some pain about the back of the neck and in the region 
of the tumor: usually slept moderately well. 

Occasionally considerable portions of the tumor sloughed 
away, noticeably diminishing its size, but subsequent 
growth soon restored it to nearly its former size. After 
death the tumor shrunk about one third. The appetite 
was good towards the last, but the food required to be 
placed in the right side of the mouth to enable it to be 
swallowed. Near the termination of the disease, there was 
some bronchitis. The patient died from inanition and ex- 
haustion. There was never any well marked cachexia. 
All pain had disappeared for several weeks before death. 



A CASE OF MALIGNANT DISEASE. 32 1 

No hereditary tendency to malignant disease could be dis- 
covered. When seventeen months of age, the child fell 
down-stairs, but without apparently doing serious injury. 
There was no history of syphilis in the family. The au- 
topsy showed that there were two tolerably distinct tumors, 
which were outgrowths from the tympanal tumor. The 
early development of the tumor was evidently from the 
neighborhood of the tympanum, as the first symptom of 
the disease was paralysis of the abducens, then of the third, 
and soon afterwards of the facial, these passing in the 
neighborhood of the growth. As the paralysis of certain 
muscles of deglutition did not occur until some time after 
that of the facial muscles, it may be inferred that the an- 
terior portion of the facial, in the hiatus fallopii, where the 
petrosal branches are given off from the intumescentia 
gangliformis, was invaded by the tumor at a later date. 
At this time, the tumor had destroyed the inner bony wall 
of the tympanum and neighborhood sufficiently to involve 
the cavernous sinuSi, 

The intra-cranial portion of the tumor is distinctly lobu- 
lated, and has in only one or two places penetrated the 
dura mater. The absence of brain symptoms seems ex- 
traordinary, in view of the fact that the brain was much 
pressed upon by the intra-cranial portion of the tumor. 
The cases herewith reported, although called different 
varieties of sarcomatous tumors (with few exceptions), 
seem in the main to exhibit the following characteristics, 
to wit: they develop more or less slowly at first, but after 
operative measures have been resorted to the development 
becomes much more rapid, and they seem to take on a more 
malignant quality. 

Autopsy by Dr. J. A. Andrews, formerly assistant sur- 
geon to the Manhattan Eye and Ear Hospital, forty-eight 
hours after death; body greatly emaciated. The dura mater 
was pale but otherwise normal. Superior longitudinal 
sinus contains a long yellowish red cord-like clot. Pia 
mater raised by a clear fluid. The removal of the brain 
displays a growth beneath the dura mater, filling the left 
middle cranial fossa and a portion of the anterior and pos- 
terior fossae. Dura mater overlying the growth is thick- 
ened and adherent to it. Surface of the growth nodular; 
one of the pedunculated projections of the tumor passes 
under the left anterior ciinoid process, displacing the nerves 
and vessels in this region. On incision the tumor presents 



322 DISEASES OF THE EAR. 

the appearance and consistency of fat. It envelopes the lower 
two thirds of the petrous bone, which is found to be carious 
in every part. The tumor extends forward as far as the 
optic foramen, and from thence to the anterior condyloid 
foramen; behind it is bounded by a horizontal line touch- 
ing the anterior condyloid foramen. The entire petrous 
portion is carious; this process terminates just behind the 
temporal suture; the squamous portion is separated from 
its articulation with the wing of the sphenoid; through 
this gap the tumor projects outward upon the face. Pos- 
teriorly, the caries extends beyond the temporo-occipital 
articulation to the foramen magnum. Behind the mastoid 
process there is a carious gap at the occipito-temporal 
articulation through which projects the portion of the 
tumor behind the ear. The superior petrosal and lateral 
sinuses are obliterated and the underlying bone is carious. 
Carotid canal and middle ear obliterated. Brain healthy, 
except the lateral ventricles, which contain 3 ij of clear fluid. 
The microscopical examination was made by T. Mitchell 
Prudden, Pathologist to the Manhattan Eye and Ear 
Hospital; and is as follows: " The intra-cranial tumor, after 
preservation in Muller's fluid and alcohol, measures 8 ctm. 
in length, 6 ctm. in breadth and 4 ctm. in thickness, and 
was attached to the inside of the temporal bone and 
covered above by dura mater. It was mostly soft and 
gelatinous, except in the central portions, where it was 
firmer and distinctly nodular. Within were small irregular 
cavities, some of them filled with blood. The dura was in 
general somewhat thickened, except over the apex of the 
nodules, where it was thinned, and in two instances was 
perforated. On the inside of the temporal bone at its 
upper portion was a broad line of jagged, irregular osteo- 
phytes. The cells of the tumor were fusiform, branching 
and spheroidal and in some parts crowded together, in 
others separated by granular or fibrillated intercellular 
substance. 

It was very vascular in many parts; the walls of many of 
the smaller vessels were considerably and irregularly 
pouched. Numerous nerves passed through the substance 
of the tumor apparently unchanged. In other places, 
single medullated nerve fibres were seen surrounded by the 
new growth. 

At the upper and inner side of the tumor and occupying 
about one fourth of its bulk, was a circumscribed and 



A CASE OF MALIGNANT DISEASE OF THE EAR. 323 

somewhat denser portion, which, in addition to the above 
described structure, presented spheroidal and ganglionic 
shaped cells and non-medullated nerve fibres. The gan- 
glion cells, which were finely granular, had large vesicular 
nuclei and sharply defined nucleoli; they were frequently 
pigmented near the nucleus, and in many cases connected 
with non-medullated nerve fibres. They were mostly en- 
closed in cellular capsules and were surrounded by the 
tumor tissue. They were as a rule, smaller than the space 
within the capsule, and in some cases the nucleus was at 
the end of the cell from which the process passed off. The 
largest had a diameter of 0.035 ni. m., the smallest 0.015 
m. m. In many places they were closely crowded together, 
and in others widely separated by tumor tissue. Every- 
where among them non-medullated nerve fibres were 
found in abundance (Fig. 86). Associated with but 




Fig. 86. — Microscopic Appearances of a Mvxo- Sarcoma. 

separated from these ganglion cells were found cells or 
cell groups so peculiar as to deserve notice. They were of 
various shapes, but in general more or less spheroidal, 
more coarsely granular than the ganglion cells, and usually 
smaller. The largest measured 0.0375 mm., the smallest 
0.0075 mm. 

They had a large irregular shaped nucleus, and usually 
a well-defined, large nucleolus. From some of them, dis- 
tinct, narrow processes were seen, passing off from one 



324 



DISEASES OF THE EAR. 



end. Many were devoid of capsules, but a large proportion 
were enclosed in a shrunken structureless non-nucleated 
capsule, which generally was larger than the cell itself. 
Among these cells were seen elongated spindle-cells, with 
rod-like nuclei. (Fig. 87) These seemed to represent gan- 




Fig. 87.— Microscopic Appearances of a Myxo Sarcoma. 

glion cells, immature or imperfectly formed. On the inner 
border of the tumor was a pedunculated nodule, about 4 
m. m. in diameter, projecting upwards, and a small nerve 
passed into its substance near its base (Fig. 88), the fibres 




Fig. 88.— Microscopic Appearances of a Mvxo-Sa.rcoma. 

of which became separated by the tumor tissue. Before 
the nerve entered the nodule it was perfectly normal. The 
fragment of the petrous bone, besides the carious con- 
dition, exhibited granulation tissue, partaking in part of 
the nature of the tumor itself. The dura mater, at points 
where it was most closely adherent to the tumor, snowed 
on its inner layer infiltration with cells similar to those 
in the tumor. The growth evidently involved the Gasse- 
rian ganglion; whether originating here or in the connective 
tissue of adjacent nerves, could not be determined. 

The rare occurrence of the new formation of ganglion 



MICROSCOPIC APPEARANCES OF MYXO-SARCOMA. 325 

cells in tumors, together with the meagreness of our 
knowledge concerning the development of cerebro-spinal 
ganglion cells under normal conditions, would suggest the 
propriety of a simple objective record of the structures in 
question without definitely attributing to any portion of 
the tumor the character of a true neuroma. 

The anatomical diagnosis would accordingly be myxosar- 
coma, involving or possibly originating in the Gasserian 
ganglion and the nerves in its vicinity, with partial de- 
struction of the petrous and other portions of the tem- 
poral bone and the soft parts within them. 

The subjoined cases, representing tumors similar in kind 
in this locality, may further elucidate the subject. 

The late Dr. C. A. Robertson, in the Tr. Am. Otol. Soc, 
1870, p. 35, reports a case of fasciculated sarcoma of the tym- 
panum : 

A woman, aet. 40, had tinnitus aurium and deafness. 
Five years afterwards there was an offensive discharge, ac- 
companied by pain and paralysis of some of the branches 
of the facial nerve. The removal of a polypus resulted 
in excessive haemorrhage. Could not hear a watch in con- 
tact; pre-auricular glands swollen; no further record. 

Wilde reports, in his text-book on the ear, a case of ma- 
lignant disease of the meatus, probably also involving the 
tympanum. 

A woman, aet. 50, whose brother died of cancer, had 
a growth in the ear, which had been in existence for many 
years; she had an unhealthy look; there was a foetid dis- 
charge. She was giddy, had nausea, and could not rest. 
The tumor was painful; it filled the meatus and was never 
wholly removed; showed a tendency to bleed, and often 
reproduced itself after partial removal; presented a fun- 
gous appearance. A fluctuating tumor of the mastoid was 
opened, from which a dark-colored foetid matter was evacu- 
ated. There was facial paralysis and abscesses along the 
mastoid muscles. The patient had rigors and convulsions, 
with excruciating pain, followed by coma. Post- and infra- 
aural regions enlarged. The integument of the mastoid gave 
way, and a fungoid mass sprouted from this region; fcetor 
intolerable. Death in three weeks from the first appearance 
of the tumor. The malignant quality of the disease 
was evidently aggravated by efforts made to remove it. 
No autopsy. 

Another case from the same source, p. 297: 



326 DISEASES OF THE EAR. 

A boy, seven years of age, had a polypus of the meatus, 
which was removed several times, but reappeared in a day 
or two; not long after this he had an epileptic fit, which 
was followed by an abscess over the mastoid region. This 
abscess cavity communicated with the meatus. A fungus 
almost immediately sprung from it; the parts in front and 
around the ear became swollen and were boggy to the 
touch; repeated attacks of epilepsy were followed by 
death. The autopsy revealed an osteo-sarcoma involving 
the petrous and mastoid portions of the temporal bone. 
The petrous portion was enlarged and softened, and pre- 
sented a fungous appearance; the internal ear was obliter- 
ated; the portion of the brain lying on the tumor was 
unaffected. 

Dr. Hartman, of Berlin, in a translation by Dr. Knapp in 
the Archiv. OtoL, March, 1880, reports a case of round-celled 
sarcoma of the tympanum. O. J., aet. three and a half years, 
was first seen in Oct., 1878. Four weeks previous to this 
he had a discharge from the ear, accompanied by pain and 
inflammation. Two weeks later a tumor in the meatus 
was observed the size of a pea; this, with others found in 
the canal, were removed as far as possible, and the parts 
cauterized; the tumor returned in a few days, appearing to 
start from all sides of the tympanum and inner end of the 
meatus. Cauterization was again done, but the tumor re- 
appeared. In October, most of the mass was again removed 
and the galvano-cautery applied. After this it reappeared 
and the surroundings of the ear became swollen, and an ab- 
scess below the ear, communicating with the meatus, was 
incised. Other tumors formed in the vicinity of the tym- 
panum and meatus. These masses were found to be round- 
celled sarcomata; they pushed the auricle outward. In 
February they were the size of a goose egg; general health 
declined. There was bronchitis, anorexia, diarrhoea, ema- 
ciation and headache. On March 21st, bilateral convulsions 
occurred, lasting several hours. A prominence in the 
right side of the fauces interfered with mastication and 
deglutition. Death occurred on March 28th; convulsions 
reappeared two days previously accompanied by coma. 

Autopsy. — The auricle was on the crest of the tumor. The 
latter consisted of a number of lobes, varying in size from 
a walnut to a hen's egg. There were ulcerated places com- 
municating with pus cavities. The upper and posterior 
walls of the meatus, roof of tympanum and a part of the 



MALIGNANT TUMORS OF THE EAR. 327 

squamous portion, destroyed; at the latter point the external 
tumor communicated with another in the cranial cavity. 
The mastoid cells were filled with the tumor. The petrous 
pyramid was easily separated from the mastoid process. 
Meatus auditorius internus free from disease. This seemed 
malignant from the start, which was exceptional, as this 
class of tumors was usually preceded by otorrhcea and 
polypi, indicating an inflammatory origin. (Most of the 
cases herewith reported seem to have been malignant at 
the commencement.) He also quotes a case from Wishart 
in the Ed. Med. and Surg. Jour. A child three years of age 
had a severe pain in the ear for some weeks with a dis- 
charge; a tumor appeared surrounding the ear, soon ulcer- 
ated, and discharged foetid bloody matter; haemorrhages 
frequently occurred and the child died in fifteen weeks from 
the commencement of the disease. The tumor was as large 
as the child's head. The petrous portion of the temporal 
bone, the zygomatic process, and the condyloid process of 
the lower jaw were destroyed. The tumor extended into a 
large orifice in the squamous portion of the temporal bone, 
forming a depression in the middle lobe of the brain, the 
latter being in other respects quite sound. Dr. Hartman 
thinks the tumor he reported sprang from the sub-mucosa 
of the tympanum. Mr. James Hinton, in his book "The 
Questions of Aural Surgery," 1874, says: " Now and then, 
but rarely, a true malignant growth simulates a polypus 
and demands caution in treatment. The general cachexia, 
the pain, the livid color, the great tendency to bleed, and 
the swelling which is always present around the ear, serve 
to distinguish the malignant growth. A soft, persistent 
swelling about the attachment of the auricle, attended with 
great pain, I have never known except in malignant disease." 
Wilde, it will be remembered, speaks of the livid color of 
the malignant growths in the ear as being characteristic. 
My own opinion, however, is that the malignant nature of 
the growth is determined with certainty only by the micro- 
scopic examination. 

It is true that the appearance of the tumor may lead to 
a suspicion of its nature. Very infrequently is there any 
true cachexia in this form of growth. Mr. J. W. Hulke, 
F.R.C.S., in the Medical Times and Gazette, Jan. 20th, 1S77, 
reports a case similar to the preceding: J. W., set. 39. The 
tumor seemed to arise from the tip of the petrous portion 
of the temporal bone. It had involved and destroyed the 
21 



328 DISEASES OF THE EAR. 

Gasserian ganglion, the third, fourth, and sixth nerves. It 
also extended to the posterior part of the orbit through the 
sphenoidal fissure; the cavernous sinus was destroyed, 
to'gether with the eighth and ninth nerves at their foramen 
of exit from the skull. No brain symptoms. The patient 
being syphilitic, a gummy tumor was diagnosticated. The 
eye-ball was inflamed and protruding; there was great pain. 
The tongue was protruded to one side; there was squint, 
myosis, etc. 

Dr. George P. Field in the London Lancet, Dec. 8th, 1877, 
reports a case of sarcomatous tumor in connection with the 
auditory nerve, in a woman aged twenty-nine years. She 
has brain symptoms; was admitted to the hospital Jan. 
29th, 1877, and died April 29th, 1877. A tumor the size of a 
Maltese orange was attached to the posterior surface of the 
right petrous bone, above the internal meatus. It resem- 
bled the cerebellum in appearance. It arose from the dura 
mater lining the meatus, and seemed to unsheath the audi- 
tory nerve. His diagnosis was round-celled sarcoma of the 
auditory nerve, of moderately rapid growth. He mentions 
two other cases, somewhat similar to this one. 

A case of fibro-sarcoma of the auditory nerve is reported 
in the Archiv. Ophthal. and OtoL, Vol. III., p. 135, by Boett- 
cher, of Dorpat. Prof. Moos in the Archiv. Ophth. and Otol.^ 
Vol. IV., 1874, p. 482, reports a case of sarcoma of the audi- 
tory nerve, in which there was fatty metamorphosis and 
partial destruction of the organ of Corti. It was a spindle- 
celled sarcoma. The cells were abundant, vessels were 
numerous, and the intercellular substance was very little 
developed. In one place the tumor was harder and trans- 
parent and in another softer and gelatinous. The patient 
was a woman forty-nine years of age. The duration of the 
disease was from August, 1870, to August, 187 1. On July 
24th, (1871) she had permanent headache, dizziness, weak- 
ness of sight, ataxic movements of the left arm (left ear 
affected), anaesthesia of left half of the face, so that the 
food fell out of that side of the mouth; swallows her food 
the "wrong way;" fluids regurgitated into the left nostril, 
rarely into the right; converging strabismus of left eye; 
left frontalis has a permanent spasm. Left arm makes 
ataxic movements, but only under impulses of the will; 
lower lip tremulous on the left side. August 1st, tem- 
perature steadily below 37.5 ; diarrhoea continued, patient 
weaker. On August nth, swallowed food the "wrong 



MALIGNANT DISEASE OF THE EAR. 329 

way," fell back with a rattle in her throat, turned black 
and died in a few minutes. There were also eye symp- 
toms. He quotes Landifort, Leveque-Lascuorce, Bruck- 
ner, Botticher, Forster, and Voltolini, as having described 
this kind of tumor. 

The causation of these tumors in general was here stated 
to be mechanical injuries and syphilis. This patient slept 
all night by an open window, and cold might have caused 
the trouble, or at least, as Moos remarks, the tumor might 
have been present before the exposure, but have been ex- 
cited to a more active development in consequence of it. 

In one hundred cases of ear disease treated by Dr. Kirk- 
Duncanson, and reported in the Edinb. Med. Jour., March, 

1878, one of malignant growth was recorded. 

It occurred in connection with purulent otitis media; the 
malignant growth distended the auditory canal and impli- 
cated the auricle. It was painful, recurred often after re- 
moval, and finally proved fatal. It was not stated what 
variety of tumor it was, but its history resembled that of 
sarcoma. 

Dr. Stevens in the Arch. Ophthalmology and Otology, July,. 

1879, reports a case of spindle-celled sarcoma of the acous- 
tic nerve. The nerve fibres were lost in the substance of the 
tumor. The patient was a girl, aged seventeen years. Ex- 
ternal recti were paralyzed, pupils sluggish. Vision f{j- in 
each eye. Hearing was lost in the left ear and impaired in 
right. Both optic disks were choked. Headache in frontal 
and occipital regions; signs of meningitis. Duration of the 
disease, several years. Towards the fatal termination her 
gait lacked co-ordination. 

In the Arch. Otol., Vol. VIII., No. 4, is reported a case of 
parotidean and intra-tympanal tumor, by Dr. Knapp. J. H. 
W., aet. 37, consulted Dr. K. on account of sudden deaf- 
ness in the right ear. Below and in front of the ear was a 
tumor the size of a hen's egg, which the patient first 
noticed six or seven years previously. During the last six 
months it had grown more rapidly. Left ear has a chronic 
otorrhcea. The membrane of the right ear was bluish red, 
convex and on pressure with a probe yielded as though a 
soft substance were behind it. Membrane punctured on 
May 8th, which penetrated a tumor and resulted in con- 
siderable haemorrhage. This tumor was touched with a 
probe and presented the appearance of a soft fleshy 
mass. 



330 DISEASES OF THE EAR. 

The parotidean tumor was thought to connect with the 
tympanal tumor through the Gasserian fissure. 

May 22d. Great pain in the ear for a day and a night. 
The aural tumor occupies half the meatus. 

May 29th. Pain relieved; an abscess has formed and pus 
escapes on pressing the tragus. 

June 20. The tumor fills the meatus. Dr. K. being ab- 
sent from town, Dr. Buck took charge of the case. 

Dr. Sands removed the tumor of the parotid on June 28th. 
This was found to have no connection with the aural 
tumor. The latter was also partially removed at the same 
sitting with Dr. Buck's assistance. 

July 28th. The incision for the removal of the parotid 
tumor has healed; pain in the ear continues; aural tumor 
increased perceptibly in size. 

This was mostly removed by incision and was followed 
by considerable haemorrhage. Other efforts at removal 
were made, but resulted in so much haemorrhage as to 
necessitate plugging the meatus with cotton wool to arrest 
it. There was little or no fibrous element in this tumor, 
and it seemed quite similar to the one I reported in the 
commencement of this article. 

Microscopic examination by Dr. W. H. Porter, of New York. 
A detailed description is given, the conclusion of which is that 
both oarotidian and aural tumors were essentially a chondro- 
sarcoma, or chondro-adenoma. Dr. Buck described it as a 
chondro-adenoma. On the same day another effort was made 
to remove the tumor, but haemorrhage interrupted it. July 26, 
the rongeur was used to remove the growth, and red-hot nee- 
dles were thrust into it to arrest the haemorrhage. Soon after 
this an abscess formed below the mastoid. Patient returned 
to his home in the country. On Oct. 25th he came to town 
and a consultation of all the surgeons who had previously 
attended him was held. The tumor below the auricle in- 
creased in size; meatus filled with a growth having fistulous 
openings in it, discharging pus; facial paralysis since five 
days; decided not to operate. Patient returned to his 
home. The tumor continued to grow until its dimensions 
were as follows: seven inches, eight inches and five inches 
in its different diameters. The ear rested on the outer sur- 
face of the tumor. No mental disturbance was observed 
during the course of the disease. Knapp refers to Schwartze 
for the literature of the subject, who had found twenty-one 
cases of malignant disease of the organ of hearing. 



MALIGNANT DISEASE OF THE EAR. 33 1 

Dr. Harlan in the Philadelphia Med. Times, Dec, 1873, re- 
ports a case of round-celled sarcoma in the ear of a girl 
three years of age. Two months before examination she 
had a bloody discharge from the ear, with pain on swallow- 
ing. There was swelling about the ear, and the face was 
drawn to the right side; meatus externus filled by a firm, 
globular polypus. Below and behind the auricle was a 
fluctuating swelling. Polypus removed and an incision be- 
hind the ear resulted in a discharge of sanious pus; subse- 
quently the growth was twice removed. Twenty-eight 
days after the first examination the tumor was of the size of 
a hen's egg, bright red, lobulated, and having a granular 
surface; complete ptosis of left eyelid resulted; conjunctiva 
became congested, the cornea was hazy and the lower por- 
tion infiltrated; sanious discharge from the left nostril. 
Seventeen days later an ulcer penetrated the cornea. 
Breathing through the mouth and nostril had become la- 
borious. In one week from this she died, apparently from 
exhaustion. 

Double convergent strabismus appeared some time before 
death, but nearly disappeared at a later date. On autopsy 
the bone at the base of the tumor behind the ear was found 
eroded, inner tympanic wall destroyed. The inflammation 
of the eye was regarded as neuro-paralytic. 



THE EFFECTS OF QUININE ON THE EAR. 

Inasmuch as quinine is administered largely for the treat- 
ment of malaria, and as the latter condition is known to act 
injuriously on the ears, it is somewhat difficult to arrive at 
an exact conclusion as to the effects of the drug on the or- 
gan of hearing. 

One fact comes out prominently enough — that on adminis- 
tering quinine in large doses, and sometimes even in small 
ones (3 to 5 grs.), the patient will have a buzzing or ringing 
in the ears with deafness and a sensation in which his own 
voice sounds hollow and unpleasant. The voices of others 
will seem to be muffled and to have an unnatural pitch. 
The Eustachian tubes may be more or less obstructed, crack- 
ling sounds will be heard in the ears from the interchange 
of air between the throat and tympanum, the tubes being 
easily forced in some instances, while in others inflation be- 
comes difficult and the patient may have a feeling of fulness 



332 DISEASES OF THE EAR. 

in the drum cavities. The throat is also frequently congested. 
These symptoms are temporary, provided the dose be not 
repeated, and disappear in a few hours or a day ; but if the 
drug is frequently repeated, the symptoms may continue, 
and cause permanent harm to the ear, according to Kirch- 
ner, in the Berliner Klinische Wochenschrift, No. 49, 1881 
(Am. Jour. Otol., Vol. IV., No. 1). He also concludes that 
the hypersemia of the tympanum may go on even to 
haemorrhage, with hypersemia of the labyrinth and injury 
to the ultimate nerve fibres. The cause of the hypersemia 
he states to be vaso-motor disturbance, which in extreme 
cases may result in paralysis of the vessels and exudation into 
the various parts of the ear. 

Weber-Liel, Monatsch. f. Ohrenheilk, No. i, 1882, in 
conjunction with Gruber, instituted the following experi- 
ments on twelve medical men. One gramme of quinia mu- 
riatica was given. In the course of two and a half hours 
the temperature of the meatus as well as that of the whole 
body fell to an average of 56 Cent. No hypersemia of the 
membrana or meatus was observed, but on the contrary in 
five cases the slight injection previously present had disap- 
peared. Roaring and buzzing or ringing sounds were always 
produced in from one to one and a half hours, gradually 
disappearing in twelve hours. After from two to three hours, 
a decided diminution of hearing showed itself, which con- 
tinued until the disappearance of the subjective noises. The 
greatest loss of hearing occurred at the period of lowest tem- 
perature. 

Dr. H. N. Spencer and others, St. Louis Medico-Chirurgi- 
cal Society, published in the St. Louis Courier of Medicine, 
Nov., 1880 (Am. Jour. OtoL, Vol. III., No. 2), discussions on 
this subject. Dr. S. some years since gave eighty grains of 
quinine to a gentleman rttending medical lectures. In a 
few minutes there was a general congestion of the vessels 
of the membrana tympani, which gradually subsided. 
There was deafness and tinnitus, which disappeared as the 
influence of the drug passed off. No anaemia succeeded 
the hypersemia. He believes it possible that in some cases 
quinine may permanently injure the hearing, but he has 
seen no case where lasting injury has resulted from quinine 
alone, other explanations of the deafness always being 
found. In the Tr. Am. Otol. Soc. for 1875, Dr. Roosa re- 
cords the following experiments concerning the effects 
of quinine upon the ear. He quotes Dr. Hammond's article 



EFFECTS OF QUININE ON THE HEARING. 333 

on the subject in the Physiological and Medico-Legal Journal, 
Oct., 1874, in which also is recorded the literature of the 
subject to that date. In this was related the experience 
of Dr. Hammond, who administered a dose of quinine to 
himself, Dr. Roosa making the observations. Dr. R. also 
repeated the experiment on others. Dr. H. took ten grains of 
quinine at 8.30 p.m. At 10.30 p.m. the right drum-head was 
very much injected along the malleus handle and upper 
margin ; left less injected. Both optic papillae were pink, left 
more so than right; face flushed, eyes suffused, ocular con- 
junctiva decidedly injected. Slight headache, tinnitus in 
both ears, auricles burn and are decidedly blushed; lobe of 
the right so congested as to resemble an ecchymosis. Most 
of these symptoms had much diminished by 11 p.m. 

Ten grains of quinine were given to Dr. E. T. E.'aet. 24. 
The experiment was similar to the last except that there 
were no symptoms but slight congestion of the drum mem- 
branes. 

Another observation was made on Dr. C, aet. 25. At 10.16 
a.m. fifteen grains of sulphate of quinine were administered. 
At 11 a.m. a vessel is seen along the malleus handle of the 
right membrane; slight vertigo. At 12.30 there is a sense 
of heat and tingling over the whole surface of the body; 
some fulness in the ears and head. Handles of both mallei 
injected, hands tremulous, sounds of a high note in the 
ears, auricles feel warm. At 12.30 the injection of the mal- 
lei, the vertigo and tremor are disappearing. At 12.50 mal- 
lei still injected, motions of the jaws cause a peculiar and 
unpleasant sense of vibration in the ears. Dr. R. refers tc 
a paper published in the Am. Jour, of Med. Sciences, October, 
1874, to show that in that paper he had expressed the opinion 
that hyperemia and not anaemia of the ears was caused 
by the administration of quinine. He refers to two other 
cases in his experience, one behaving somewhat similar to 
those already reported, and the other showing no conges- 
tion of the ear whatever; the latter case, however, was one 
where quinine had been habitually taken and the patient 
was anaemic. Dr. R. expresses the opinion that the tinnitus 
and deafness " following the use of quinine depend upon 
congestion of the ultimate fibres of the auditory nerve in 
the cochlea, and that the redness of the drum-heads is 
merely an index of the former condition." In the Trans. 
Am. Otol. Soc, 1872, p. 57, Dr. Roosa also reports a case 
where an inflammation of the tympanum, followed by im- 



334 DISEASES OF THE EAR. 

paction of cerumen, occurred wherethe otitis, "although to 
a certain extent dependent upon the naso-pharyngeal ca- 
tarrh," was " chiefly caused by the use of quinia. By look- 
ing at the history and observing how promptly and invari- 
ably the pain in the ears occurred in several instances after 
the use of the agent (quinine), we are forced to the conclu- 
sion that quinine was the exciting cause of the aural in- 
flammation." He remarks that this case illustrates the 
effect of quinine upon the ear, "which I am inclined to 
suspect is sometimes an inflammation of the conducting 
portions, as well as of the acoustic nerve or labyrinth." Op- 
posed to the ideas here presented except those of Weber- 
Liel, are those of Knapp {Z.f. O., Vol. X., p. 279) — Politzer's 
reference — who, " in cases of blindness and deafness caused 
by large doses of quinine, observed excessive paleness of the 
disk of the optic nerve with almost complete invisibility of 
the retinal vessels; and he believes that a similar state in 
the cochlea causes deafness." The practical point regard- 
ing these matters seems to be to avoid quinine in cases 
where it is plainly obnoxious, and select some other salt of 
Peruvian bark. I have found the sulphate of cinchonidia 
reasonably effective though perhaps not as much so as 
quinine, and it causes very little disturbance to the ear func- 
tions in doses sufficient to accomplish results. Those who 
have confidence in dextro-quinine may use that remedy, as 
it is not likely to effect the ears unpleasantly. All the other 
salts of Peruvian bark are less likely to injuriously affect the 
ears than quinine. [Bromides of potass, and sod. with the 
quinine diminishes the ill effects.] 

AFFECTIONS OF THE EAR INFLUENCF-D BY OR DEPENDENT ON 
MALARIA AND DEFECTIVE DRAINAGE. 

The matter contained in this topic is extracted from an ex- 
tended article by the author in the N. Y. Med. Record for 
Jan. 31, 1885, p. 113, et seq. It seems a little uncertain how 
far the influences of malaria and defective house sanitation de- 
termine ear affections. 

I purposely include defective house sanitation, for, although 
many authors oppose the notion, the somewhat vague condition 
known as malarious, at least in this region, seems strongly to 
be influenced by the sanitation of the individual house. There 
is undoubtedly little malaria in New York, and where found 



AFFECTIONS OF THE EAR INFLUENCED BY MALARIA. 335 

may, in my opinion, be traced to defective plumbing. So far, I 
do not conclude that the diagnosis can be sharply drawn be- 
tween the ill influences of imperfect house sanitation and what 
is known as malaria, pure and simple. In the article to which 
reference has been made I had called on the opinions of many 
aural surgeons in this country, including Canada, and shall 
make extracts from them, confining myself to those statements 
which favor the theory of malarial affections of the ear. One 
of the earliest and best accounts of malarial ear affections may 
be found in the Monatschrift fiir Ohrenheilkunde, No. 11, 187 1, 
by Weber- Liel. He describes two forms of ear disease depend- 
ent on malarial poisoning : one an inflammatory affection, otitis 
intermittens ; the other a non-inflammatory affection, otalgia 
intermittens. Both varieties are referred by him to malarial 
neuralgia of the third branch of the trifacial nerves — the otalgia 
being a malarial neuralgia ; the otitis being an inflammatory 
affection. He describes some of the symptoms thus : Gener- 
ally there has been a preceding angina or catarrh, when to- 
wards evening or in the night there is a chill, either decided or 
perhaps so slight as scarcely to be noticed ; this is followed by 
a feeling of fullness and roaring in the ears, and sometimes by 
vertigo and pressure in the head ; profuse perspiration follows, ! 
and by the next day the ear symptoms have disappeared. I 
Forty-eight hours or so afterwards there is another chill, pains 
in the ears, deafness, tinnitus, and with exudation into the tym- 
panum. After the perspiration the patient is completely re- 
lieved except of the noises. If the exudation in the tympanum 
has ruptured the membrana the discharge ceases by morning, 
and the pain is relieved. Thus the attack continues, following 
the quotidian or tertian type, until the ear affection becomes 
continuous instead of intermittent as at first. Ordinary treat- 
ment is unavailing, but quinia affords speedy relief, especially 
to the tinnitus, which in other cases it would aggravate. Vol- 
tolini, Monatsch. f. Ohrenheilk., May to July, 1878, publishes 
similar observations, but regards the affection as more neural- 
gic than inflammatory, and designates it otalgia intermittens. 
The late J. P. Cassels, M. D., etc., in the Edinburgh Med. 
Journal, Vol. XXIII., p. 910, reports a considerable number of 
ear cases where the otitis seemed distinctly traceable to defec- r 
tive house drainage. All his cases showed signs of nasopha- 
ryngeal catarrh, and dampness was a characteristic of the houses 
of many of the patients under observation. The evidence 
seemed to point to the fact that the ordinary exciting causes of 
aural catarrh existed, in addition to the other, possibly pathogen- 



336 DISEASES OF THE EAR. 

etic condition. The case of Dr. S., reported in full in Dr. Roosa's 
work on the ear — edition of 1885 — may fairly be regarded as 
an ear affection, caused, or at least modified, by defective 
house drainage. Dr. Roosa sums up the case in these words ; 
" It was simply a case of sub-acute, non-suppurative inflamma- 
tion of the Eustachian tube and tympanic cavity, occurring in 
an anaemic and consequently neuralgic . . . subject." 
The affection continued from May 5, 1879, with varying re- 
sults, until June 19th. The cure was finally effected by the ex- 
hibition of quinine, arsenic, iron, alcoholic stimulants, and nour- 
ishing food. Dr. Roosa believed that the patient's original 
disease depended on overwork, and living in a house with de- 
fective plumbing. In this case the neuralgic element was very 
prominent, as I have suspected that it was likely to be in other 
similar instances. Dr. J. Orne Green, in the Amer. Jour, of 
Otology, April, 1879, reports a case of otitis intermittens in the per- 
son of a serving-maid living in a house in Boston, located on 
" made " land, with undoubted evidence of defective sewage. 
" This case differed from an ordinary form of catarrhal inflam- 
mation, in the preceding slight chill, the marked neuralgia of 
the trifacial, in the fever, swelling of the face, and hyper- 
esthesia, in the relief of the neuralgia by the perspiration, and 
in the congestion and discharge from the ear, following the 
other symptoms after a few hours usually, and coming on 
rapidly and diminishing with nearly equal suddenness, these 
attacks recurring every few days for four months." Dr. F. C. 
Hotz, in the American Specialist iox March 1, 1881, reports on 
intermittent otitis, and observes that where every other means 
of relief failed, the administration of quinine resulted in speedy 
relief. Hotz and several others have referred to one charac- 
teristic of otitis intermittens, in which there was great intoler- 
ance of local treatment. I cannot believe that this is a pecu- 
liarity of the affection. The following case was treated by me 
at the hospital : A man, aged 29, applied for treatment on 
September 26, 1883. In July he caught cold in the left 
ear, which pained him for two weeks, when rupture of the 
membrane and discharge gave relief. This discharge soon 
ceased. About three weeks before he applied to me he again 
had pain in this ear, which was soon followed by a discharge. 
The pain in this instance was not relieved by the discharge, 
was very severe, and extended over the side of the head to the 
occiput ; hearing nearly abolished. Granulations were re- 
moved from the tympanum ; leeches were employed with only 
partial success, as the pain subsequently returned. On October 



AFFECTIONS OF THE EAR INFLUENCED BY MALARIA. 337 

1st the pain was promptly relieved by ten grs. of quinine t.i.d. 
for two days. Since this a tender spot has appeared behind 
the angle of the jaw, and the pain has returned. There being 
considerable discharge a 40-gr. solution of arg. nit. was poured 
into the ear, and allowed to remain. October 10th, pain and dis- 
charge relieved. On the 12th the same application was repeated. 
Hears the watch at one inch ; perforation healed. October 
15th, sent home with the hearing still further improved. The 
patient came from a malarious region on the Hudson River ; 
had recently an attack of ague, and I infer that the prompt 
action of the quinine in relieving the pain was an indication of 
its malarious nature, but proof of this does not absolutely 
exist. Among the opinions I elicited by my correspondence 
I may mention the following, although several of them did not 
believe in the malarious nature of any form of otitis. Dr. 
Holmes, of Chicago, says : " I have seen many cases of disease 
of the ear modified by malaria, and have prescribed quinine in 
nearly every case of continual inflammation of the middle ear, 
especially if accompanied by much pain ; in fact, this is so 
much a habit that I have little experience in knowing the course 
of inflammatory diseases of the ear without quinine." Dr. 
Miller, of Providence, finds it difficult to settle the diagnosis. 
" I have simply said chronic or acute catarrhal otitis media 
complicated with malaria or aggravated by quinine." Dr. 
Blake, of Boston, has " no experience in malarial affections of 
the ear to any extent, except in cases which I have had from 
the West — chronic cases, in which large quantities of quinine 
had been taken." Dr. St. John, of Hartford, had not met with 
many ear affections which he regarded as distinctly malarial. 
Some of his patients dated their trouble to a malarial attack, 
but the large doses of quinine taken had complicated the 
etiology. Dr. Buck, of N. Y., observed that in a few of his 
mastoid cases, on the second or third day after an operation 
there was a rise in temperature, a depreciation of the patient's 
tone — loss of appetite, increased discharge of pus, r turn of 
headache, rapid and feeble pulse — which he ascribed to mala- 
rial influence. This condition was gradually relieved by fifteen 
to thirty grs. of quinine daily for a few days. He has seen 
only a few cases of otalgia which he suspected to be of malarial 
origin. The success of quinine in relieving ear symptoms 
favored a theory of malarial origin, but did not prove it. Dr. 
Seely, of Cincinnati, has seen an example, and perhaps examples 
of serous effusion into the tympanum, due to malaria. He 
seems to believe that otalgia may be due to malaria, and that it 



338 DISEASES OF THE EAR. 

is curable by quinine. He further says : "lam constantly in 
the habit of giving quinine under all circumstances, even in 
acute otitis media catarrhalialis, orpurulenta in children, where 
there seem to be indications, and expect and find, so far, 
only benefit." Dr. Frank, of Baltimore, recalled a single case 
of distinctly intermittent tinnitus, dependent on malaria, and 
which was cured by arsenic and quinine. Dr. Todd, of St. 
Louis, says : " It is customary here to give quinine freely in 
' catarrhs ' with persistent fever, in which cases the ears are 
apt to be involved, secondarily probably." Dr. J. A. Andrews, 
of N. Y., has seen an acute exacerbation of middle ear trouble, 
which he believed to be distinctly traceable to the malarious 
attack. Dr. Jones, of Chicago, says : " That malarial poison- 
ing may complicate existing inflammation of the ear, or may 
even cause a neuralgic pain in the ear, may readily be con- 
ceived," etc. I am loth to believe that even if we admit the 
malarial causation of otitis, the resulting inflammation has any 
peculiar characteristics. 

Another point stands out prominently, that in many reported 
cases of malarial otitis the element of dampness enters as a 
factor in the causation of the affection, which would come 
under the head of a catarrhal causation. On the Other hand, 
it is admitted that the presence of dampness in a malarial region 
favors the development of malaria. It is also true that general 
unhygienic influences predispose to malaria in such regions, 
which are also factors in the causation of an otitis. Tonics 
generally are known to be useful in chronic otitis, but the noto- 
riously felicitous influences of quinine in a malarious region on 
a great variety of diseases, including otitis, compels one to sus- 
pect a malarial element in the pathogenesis of this affection. 

SYPHILITIC INFLAMMATION OF THE MIDDLE EAR, THE LABY- 
RINTH AND ACOUSTIC NERVE. 

I treat these subjects under one heading for the reason 
that in practice most of the cases met with come under the 
designation of middle ear affections with or without laby- 
rinth complications, the labyrinth often suffering in its 
functions, whether it be the seat of organic disease or not. 
Moreover, the difficulty of always stating how far the laby- 
rinth is involved in a given case, is sometimes well-nigh in- 
surmountable. In one class of cases few symptoms may 
be elicited except those of ordinary middle ear disease. 
There is some discrepancy in the statements of different 
authors as to whether the Eustachian tubes are pervious in 



SYPHILITIC INFLAMMATION OF MIDDLE EAR, ETC. 339 

specific otitis media. Most agree that the tubes are pervi- 
ous, and that there is little or no improvement to the hear- 
ing after inflation. My own impression is that there are at 
least numerous exceptions to this rule, the middle ear affec- 
tion exhibiting symptoms quite similar to those found in 
ordinary middle ear disease. Vertigo, nausea, vomiting, 
unsteadiness of gait, etc., are laid down as characteristic 
symptoms of syphilitic otitis, especially where the functions 
of the labyrinth are disturbed. As so many other ear affec- 
tions have these symptoms, they cannot be regarded as 
altogether peculiar to this disease. The vertigo is likely to 
be a persistent symptom. Rapid or sudden loss of hearing 
is certainly a characteristic of specific otitis. The hearing 
may be hopelessly spoiled in a day, or it may be a year or 
two before profound deafness results, but in either event 
the hearing is lowered much more rapidly than in a non- 
specific affection. Tinnitus aurium is present in a consid- 
erable number of cases, although in some instances there 
is a surprising absence of subjective sounds in the ear. 

This disease, on the whole, is a somewhat painless one, 
although specific neuralgias about the head are frequent, 
the pain running down the spine or either arm; as this is 
often nocturnal, it has been regarded as characteristic of 
syphilis. As in other grave ear affections, the patient may 
be despondent, and suffer from a treacherous memory, with 
loss of appetite, constipated bowels, and other signs of sys- 
temic disturbance. Sometimes, though not often, optic 
neuritis accompanies this affection. Paralysis of the faci- 
alis is a somewhat frequent symptom. Sometimes both 
nerves are paralyzed, when the patient is unable to open 
his mouth. 

The facial is much more likely to be diseased in its pas- 
sage through the hiatus Fallopii than in ordinary middle 
ear trouble. Paralysis of the facialis from a lesion at the 
inner auditory meatus is not an uncommon occurrence. 
Hemiplegia and even paraplegia may accompany this form 
of otitis. Epileptic seizures are not of very infrequent oc- 
currence. Double vision with strabismus is sometimes 
seen, more frequently in consequence of paralysis of the 
abducent muscle. Many other symptoms dependent on 
syphilis might be enumerated. Ordinarily there is no dis- 
charge from the ear, but occasionally a suppurative otitis 
will be modified by the constitutional dyscrasia. Thus 
Buck, Am. Jour. Otol., Vol. I., No. 1, mentions a case where 



34° DISEASES OF THE EAR. 

the suppurative process resulted in carious bone at the 
inner end of the meatus externus, and another where two 
perforations occurred in the membrana, the latter seeming 
to melt down by a destructive process resembling that 
sometimes seen in tuberculous suppuration of the middle 
ear. It was the opinion of Buck, in the case of the carious 
bone, that as there was a free outlet for purulent products, 
that the caries would not have resulted had it not been for 
the syphilitic influences. The throat affections accompany- 
ing the middle ear disease, besides having nothing charac- 
teristic of syphilis, may have all the peculiarities of syphi- 
lis, as warty or gummous growths, deep ulcerations, per- 
forations ot the uvula, velum, etc. Many authors, among 
whom are C. H. Burnett {Amer. Jour, of OtoL, July, 1881) 
and Samuel Sexton {Amer. Jour, of Ctol., October, 1880), 
conclude that similar changes are likely to occur in the 
middle ear to those in the throat, even when inspection 
of the membrane gives no hint of a diseased tympanum. 
Both ears are usually attacked, but sometimes one remains 
healthy while the other may suffer from well-marked syphi- 
litic disease. Little can be said about the appearance of 
the membrana. It very frequently does not differ in ap- 
pearance from that in non-specific disease. Generally a 
dry looking membrane moderately reddened, with little or 
no cerumen in the canal, possibly with redness at the inner 
end of the meatus, is all that may be ordinarily seen, or 
there may be no hyperaemia of the membrane at all. 
Signs of infiltration of the membrane, giving it a greater 
degree of opacity than would result from a non-specific in- 
flammation, will cause one to suspect constitutional disease. 
The most important aid, however, to diagnosis is the his- 
tory. 

Pathology. — It is extremely difficult to determine in all 
cases whether the lesions are in the middle ear, in the laby- 
rinth, or in the acoustic nerve. I believe in a majority of 
cases that the middle ear will be found diseased. It is true 
that the Eustachian tubes will be pervious in a large num- 
ber of cases, and that no improvement to hearing results 
from inflation. It is interesting to note the impression Sir 
William Wilde had of this class of cases. He says in his 
book on the Ear (Amer. Ed., p. 255): "This inflammation 
does not end in muco-purulent discharge from the tym- 
panum, the surface of the membrana tympani, or the sides 
of the auditory canal; nor have I seen lymph effused upon 



SYPHILITIC INFLAMMATION OF MIDDLE EAR, ETC. 341 

the membrane, as in the more violent and painful forms of 
otitis; but from its brownish red color in the very early 
stage, from a yellowish speckled opacity, which is gener- 
ally observable in it on the subsidence of the redness, and 
from the intense degree of thickening and dulness w r hich 
were present in some cases, which were evidently the result 
of syphilitic disease, I am inclined to think that the lymph 
is largely effused between the laminae or upon the inner 
surface of the membrana tympani. Two of the worst cases 
of non-congenital deafness I ever saw appeared to have 
been the result of syphilitic inflammation, and in both there 
was great thickening, opacity, and insensibility of the mem- 
brane. I am also inclined to think that syphilis has played 
a more extensive part in the production of deafness than 
we are aware of." 

On page 256 he reports a case the exact counterpart of 
the description just quoted. The patient had undergone 
the usual local treatment without a particle of improve- 
ment. Afterwards mercury was given by the mouth. "This 
mode of administering the mineral disagreeing, we were 
obliged to discontinue it, and substitute inunction in its 
stead. The deafness and the appearance in the ear re- 
mained unaltered until the morning on which salivation 
was produced, and then hearing was restored almost mirac- 
ulously, and the next day the redness and vascularity in the 
ears had almost disappeared." There was no return of the 
deafness. I will not attempt to assert, in the absence of 
the tuning-fork observations, that this was a case of middle- 
ear disease alone, but I infer that it was. I also conclude 
that an ordinary otitis would not have improved so sud- 
denly under the influence of mercury. Following Wilde's 
opinion that there is infiltration within the tympanum, 
Sexton (Am. Jour. OtoL, Oct,, 1880, p. 308); says "As re- 
gards the pathology of this syphilitic invasion of the mid- 
dle ear, it may be surmised that granuloma, or circum- 
scribed small round-cell infiltration, takes place within the 
tympanum — that the invasion is rapid, and that the conduc- 
tive apparatus is prevented from performing its movements 
by the particular manner of fixation that occurs. It is 
doubtful if our present means of pathological study could 
definitely determine its present seat in all cases." C. H. 
Burnett quotes with approval this extract, except the last 
sentence, in a clinical contribution to the Am. Jour. Oto/., 
July, 1881. He also, finding a syphilitic wart on the uvula 



342 DISEASES OF THE EAR. 

of the patient in question, concluded that there was a sim- 
ilar condition in the tympanum. Sexton states, Tr. Aitier. 
Otol. Soc, 1878, that " the sudden deafness of syphilis has, 
beyond doubt, its principal seat in the conducting mechan- 
ism, for in all such cases which I have examined the vibra- 
tions of the tuning fork, when placed on the head, are transmitted 
through the tissues to the auditory nerves, a?id are heard; and the 
patient can hear distinctly his own voice." Buck states, Amer. 
Jour. Otol., Jan., 1879, that " the mucous membrane lining 
the niche for the round window, or the membrana tympani 
secondaria itself, may become congested and very much 
swollen, without narrowing of the Eustachian tube, without 
the exudation of fluid into the middle ear, and without the 
slightest change in the condition of the drum membrane. 
. . . The swelling of these parts, and especially of the 
secondary tympanic membrane, cannot take place without 
producing pressure upon the fluid of the labyrinth." He 
still further discusses the subject of interference of the 
function of the acousticus from middle-ear syphilis, and even 
of organic changes secondarily induced by the middle-ear 
affections, and ends by saying that " In the present state of 
our knowledge of aural pathology, therefore, we are hardly 
justified in using the expression 'labyrinthine disease,' ex- 
cept in those cases where demonstrable lesions are found in 
this part of the ear at the post-mortem examination." Dr. 
F. R. Sturgis, in the Bost. Med. and Surg. Jour., June 3, 1880, 
p. 532, speaks of the " infiltration of the tympanum con- 
joined with absence of vascular congestions" as character- 
istic of syphilitic otitis media, and "not, I think, common 
to the ordinary forms of middle-ear trouble." He speaks 
of one case of old suppurative otitis media which had be- 
come convalescent and presented the usual changes inci- 
dent to that disease. The right ear subsequently became 
attacked by syphilis; when the membrana "became succu- 
lent, looking as if it were infiltrated with fluid and air; 
exudation had taken place . . . which diminished very 
considerably in size as the syphilis improved." Buck fur- 
ther states that in one class of cases (loc. cit., p. 39) the 
drum membrane showed a tendency to breakdown under the 
syphilitic inflammation, often causing more than a single 
perforation, similar to that which frequently may be seen 
in the velum in syphilitic subjects. In his case No. XII. he 
concludes that "the development of caries and facial par- 
alysis with no evidence of interference with the free escape 



SYPHILITIC INFLAMMATION OF MIDDLE EAR, ETC. 343 

of the pus formed, was certainly not in harmony with the 
ordinary course of a non-syphilitic otitis media purulenta 
acuta." 

Numerous cases on record exhibit paralysis which ap- 
pears concurrently with the deafness. In this class of 
cases it would not be unreasonable to infer a hypersemia 
of the acoustic and facial nerves at the internal meatus, 
with infiltration; or a periostitis in that vicinity, or a gum- 
ma— a concatenation of symptoms perhaps not dissimilar 
to what occur in specific neuro-retinitis. Dr. F. M. Pierce, 
in the TV. International Med. Congress, London, 1881, Vol. 
III. p. 399, says: "The evidence of syphilis attacking the 
middle ear is mainly of a catarrhal character, with a marked 
prevalence of anomalous auditory nerve symptoms, and in 
adults these symptoms are suggestive of acquired or con- 
genital syphilis as a predisposing cause." I am firmly of 
the belief that the naso-pharyngeal and middle ear catarrh 
of syphilis very often does not differ in appearance from 
that dependent on other causes, but that its peculiar nature 
is revealed by the rapidly curative effect of mercurial treat- 
ment. This is, however, denied by some. I am inclined 
to believe that any peculiar appearance of the throat 
which is characteristic of syphilis may be repeated in the 
tympanum, the inflammation travelling up the Eustachian 
tube to involve the middle ear. Roosa says (Text-book, 
4th Edition, p. 521), after recognizing the fact " that syphi- 
litic affections of the middle ear are perhaps more common 
than those of the labyrinth," goes on to say that " we have 
good reason for believing that we may have hyperemia 
and periostitis of the labyrinth, as well as gummata." 
Sometimes the paralysis extends so that the patient be- 
comes hemiplegic. Occasionally both facial nerves become 
paralyzed, as in one case reported by Sexton (loc. cit.), 
where the patient was unable to open his mouth. 

Diagnosis. — If only catarrh of the middle ear exists with- 
out any of the characteristic signs of a specific lesion, the 
syphilitic history, the obstinacy of the affection under or- 
dinary treatment, the proneness to lowering of the hearing 
more rapidly and to a greater degree than in non-specific 
catarrh, and lastly the wonderful effect frequently result- 
ing from constitutional treatment, will point with consid- 
erable certainty to the true nature of the affection. In 
other cases the throat will exhibit so many of the signs of 
specific trouble as to at once place the surgeon on the right 
22 



344 



DISEASES OF THE EAR. 



track of investigation. The appearance of the membrana 
is not a valuable guide on the whole. If there is only mod- 
erate redness of the membrana, the inner end of the meatus 
reddened, dry looking, and the membrane has a degree of 
opacity or is infiltrated out of proportion to the amount 
of inflammation present, and there is absence of any con- 
siderable pain in the ear, suspicion may be entertained of 
specific trouble. 

Vertigo, nausea, vomiting, unsteadiness of gait, etc., 
are very frequently met with, but are not diagnostic of 
syphilis, or even of labyrinthine disease. The rapid or sud- 
den loss of hearing, apparently without sufficient local 
cause, is a valuable diagnostic of syphilitic otitis. False 
hearing or double hearing proves that Corti's organ is 
functionally affected; so also does the failure to hear higher 
tones of the piano while the lower ones are heard. Sen- 
sitiveness to harsh or loud sounds, the unpleasant and dis- 
cordant perception of harmonies, proves that the region of 
the cochlea is functionally affected, but not that the dis- 
ease is located in that region. The tuning-fork is of diag- 
nostic value in eliminating middle ear complications; but 
even here the exceptions of intermittent bone conduction 
will often make an exact diagnosis well-nigh impossible. 

I conclude that sudden and absolute deafness without 
middle-ear symptoms is the most certain diagnostic symptom 
of labyrinthine or nervous trouble. Sudden facial paraly 
sis and deafness, as Roosa (I.e.) has mentioned is diagnostic of 
disease located in the internal ear or the acoustic nerve. 
Again, a pervious Eustachian tube, with absence of disease 
of the membrana tympani, does not prove absence of middle- 
ear complication. The greatest trouble in diagnosis will be 
in those cases where the middle ear is known to be diseased, 
to determine how far the acoustic nerve or labyrinth is in- 
volved. In most of the published cases of ear syphilis the 
tuning-fork and other tests have not been made with 
sufficient thoroughness to determine all that may be known 
of the exact locality of the lesion. This matter will test 
expertness of diagnosis more than most subjects. 

The prognosis is of the gravest nature. Much turns on 
the commencement of treatment before profound deafness 
has overtaken the patient. After that period little can be 
done, although a few cases are reported where recovery 
has resulted, as Wilde puts it, in an almost miraculous man- 
ner, where the deafness had become profound. In most 



SYPHILITIC OTITIS MEDIA, ETC. " 345 

of the cases of non-implication of the middle ear with sud- 
den and extreme deafness, the prognosis is very unfavor- 
able. Where little is at fault except the middle ear, a very- 
hopeful prognosis may be given, as the mercurial influence 
is often wonderful in relieving these symptoms. The pres- 
ence of a number of paralytic symptoms renders the 
prognosis nearly hopeless. 

The conditions under which the affection is developed. — Natu- 
rally, the syphilitic poison is capable of inducing disease 
in any part of the hearing apparatus, but we also have the 
element of exciting causes to consider. For instance, a 
syphilitic subject takes on a simple catarrhal otitis. This 
often follows the law of a specific affection, and the patient 
may suddenly become permanently deaf. Again, a patient 
may have had an otitis from which he has become conva- 
lescent, when, on syphilis attacking the organism, a relapse 
may occur in consequence of the syphilis. The condition 
of the mouth may act as a predisposing cause to specific 
otitis — bad teeth, diseased gums from wearing badly fitting 
artificial teeth, the vulcanite plate, etc. 

Treatment — All middle-ear and throat symptoms may be 
treated according to the rules already laid down under the 
heading of Chronic Otitis Media, with the hope that the 
symptoms may not require specific treatment. As numer- 
ous adhesions are likely to form within the tympanum, it 
is well enough to try exhaustion, with alternate condensa- 
tion of the air in the meatus externus, by means of Siegle's 
tympanoscope or its equivalent, as practised by Pinckney, 
Sexton, Brandeis, and others, with a view to rupture them 
or break up any anchylosis of the ossicula. I have practised 
this method, however, with indifferent success, on the 
whole. Local means proving unsatisfactory, resort may 
be had to mercury and iodide of potass. The form of 
mercurialization most effectual is by inunction. The older 
methods may be employed, or the more modern one of 
oleate of mercury — a half drachm of a twenty-per-cent solu- 
tion, rubbed daily into the skin, or any convenient part of 
the body. It is well not to delay the treatment too long. 
It should be commenced with considerable energy, as valu- 
able time may be lost; avoid salivation if possible. The 
late Dr. F. J. Bumstead often used the blue pill, some- 
times continued for months together, without ptyalism, and 
with great success. In children, inunction may be used, 
but the hyd. c. creta, given internally, will be perhaps 



346 DISEASES OF THE EAR. 

a better method. It is often desirable to give a tonic — iron 
or some of the bitter tonics — while the inunction is being 
applied. Some administer the iodide of potassium during 
the inunction. I prefer the use of the mercury for from 
one to several weeks, then alternate with the potass, iodid. 
When the specific symptoms verge upon the tertiary, and 
sometimes in the secondary stage, the iodide of potass will 
accomplish wonders, provided it is exhibited in sufficiently 
large doses. The neurologists have made innovations in 
this respect. I have seen two hundred grains of the iodide 
given daily, at the Manhattan Eye and Ear Hospital, to a 
child of six, for symptoms of basilar meningitis. It was 
perfectly well borne. Roosa (1. c.) reports cases of spe- 
cific otitis, where the amount of the iodide administered 
daily reached the enormous quantity of three hundred and 
sixty-nine grains. He also observed that several cases 
showed improvement only when the larger doses had been 
administered. It usually seemed to be well borne. 

It is good practice, as recommended by A. Seessel, M.D., 
of the Manhattan Eye and Ear Hospital, to take the iodide 
well diluted with water during the meals and in di- 
vided portions, as in this manner it may be better digested. 
Hyperaemia and opacities of the membrana tympani some- 
times disappear with great rapidity under proper consti- 
tutional treatment. Mercurial baths often succeed well in 
those who are too feeble to bear treatment by other means. 
As long as the hearing improves, the treatment should be 
continued. In any event, if there is good reason to believe 
that syphilis is at the bottom of the trouble, a thorough 
course of mercury and iodide of potass, is justifiable, al- 
though there may be no improvement in the hearing for 
weeks together. All possible means for supporting the 
patient's strength should be resorted to. In accordance 
with the general principle, when there is a tendency to 
destruction of tissue, iodide of potass., tonics, improved 
diet, and perhaps stimulants, may be recommended. 

The paralytic symptoms may be treated by electricity. 
On the whole, Galvanism is more likely to benefit than 
Faradism. I do not believe that electricity will benefit the 
hearing, and therefore do not recommend it for that pur- 
pose. In accordance with the general principle of main- 
taining the patient's health, it may sometimes be proper 
to send him to a more congenial climate, giving him the 
benefit of change of air and scene. 



HEREDITARY SYPHILIS OF THE EAR. ^y 



AFFECTIONS OF THE EAR DEPENDENT ON HEREDITARY 
SYPHILIS. 

For the most part these are " mixed " cases, although the 
labyrinth is more frequently involved than the middle ear. 
Ordinarily the affection follows that of a parenchymatous 
keratitis or kerato-iritis in a subject of syphilitic parentage. 
The patient usually, although not always, shows the notched 
and ill-developed teeth described by Hutchinson as charac- 
teristic of hereditary syphilis. The ear affection does not 
occur nearly as frequently as the eye lesion, there being six 
or seven eye cases to one of the ear. Ordinarily the ear 
symptoms come on at about the time the eye is convalescent 
or soon after, although it may precede the eye symptoms, 
or there may have been none of the latter, or the eye symp- 
toms may alternate with those of the ear. An important 
characteristic of the affection is the more or less sudden loss 
of hearing — much more so than could be accounted for had 
the patient only middle-ear disease. The hearing may be 
mostly abolished in one day, or some months may elapse 
before the patient reaches his extreme point of hardness of 
hearing. Girls are more subject to this disease than boys, 
in the proportion of three or four to one. In boys a period 
somewhat after the age of puberty is the one in which the 
attack is more likely to occur. In girls the attack more 
frequently occurs at puberty. In Kipp's six cases (Tr. 
Am. Otol. Soc, 1880), the ages ranged from six to twenty- 
three years. Where the hearing is restored it is at a period 
subsequent to that of the convalescence of the accompany- 
ing eye affection. At the commencement of the attack, 
vertigo, nausea, vomiting, unsteadiness of gait, frontal or 
occipital headache, possibly sleeplessness, deafness, as pre- 
viously stated, tinnitus, although the latter is not constant, 
absence of pain about the ear, and in some instances head 
symptoms occur. The ear symptoms may vary with the pro- 
gress of the eye affection — that is, may be more declared 
when the eye affection is progressing favorably, or may show 
improvement during a relapse of the eye trouble. Sooner or 
later both ears are likely to be attacked, whether simultane- 
ously or one following the other after a brief period, does not 
exactly appear where there are middle-ear complications. 
Naturally the symptoms of that affection will be added to 
those already enumerated, although it may be remembered 



348 DISEASES OF THE EAR. 

that vertigo, unsteadiness of gait, nausea, vomiting, and 
pseudo head symptoms may result from middle-ear affec- 
tions alone. As a rule, the Eustachian tubes are found to be 
pervious, and little or no improvement to hearing results 
from inflation. Bone conduction was found by Kipp (loc. 
cit.)to be unaccountably good ; but he concluded that as 
his patients were not of a high order of intelligence, that 
they often mistook the feeling of vibration of the tuning- 
fork for actual hearing. I have often been able to make this 
differentiation myself. I conclude that the suddenness of the 
loss of hearing, especially when there is absence of middle- 
ear symptoms, amounts to proof of labyrinthine or nervous 
involvement. Another point which Kipp calls attention to is 
the fact that even when middle-ear trouble is present the 
restoration of the hearing is delayed long after complete 
recovery of the middle-ear disease ; whereas, if it were only 
the latter which has caused the deafness the restoration of 
the hearing would occur before all of the middle-ear 
symptoms had subsided. According to Roosa (Text Book 
on Diseases of the Ear), if the labyrinth is the seat of the 
lesion the patient will hear the upper tones of a piano at 
some period of his disease badly, while the lower tones are 
more likely to he heard well. Without further argument, I 
conclude that the lesion on which much or most of the deaf- 
ness depends is principally in the acoustic nerve or laby- 
rinth. I am aware of the great difficulty of determining in a 
mixed case how far nervous involvement has taken place, 
and am ready to admit that there is much reasonableness 
in the conclusions of such authors as Sexton and C. H. 
Burnette, that middle-ear trouble is often the sole lesion in 
the deafness of syphilis. Under the heading " On the Use of 
the Tuning-Fork" will be found a brief discussion of inter- 
mittent bone conduction, from which it will be seen that 
some of the cases reported as labyrinthine or nervous deaf- 
ness have not been recorded with perhaps sufficient careful- 
ness to eliminate this source of fallacy. I am inclined to 
think that with more exact observation a greater number of 
middle-ear causes of deafness and fewer of labyrinthine in 
this class of cases will be found. Naso-pharyngeal catarrh 
very frequently accompanies this form of ear disease, and 
is undoubtedly in many instances a consequence of the 
constitutional dyscrasia. There is evidence enough to show 
that this catarrh often passes into the tympanum and from 
thence to the labyrinth, through the oval and round win- 



HEREDITARY SYPHILITIC AFFECTIONS OF THE EAR. 349 

dows. As far as I am able to observe, this catarrhal pro- 
cess differs very little from that dependent on other causes, 
except that in the labyrinth there seems to be a stronger 
tendency to hyperemia and proliferation, and that in the 
pharynx the tendency to destruction of parts is greater than 
in other forms of catarrh. Witness the frequent perforation 
of the uvula and deep ulcerations often found elsewhere in 
the upper pharyngeal space; purulent inflammations of 
the tympanum have been noticed by Schwartze and others 
as a characteristic of hereditary syphilis, but these seem to 
make a good recovery. 

The Prognosis is exceedingly unfavorable, many cases go- 
ing on from one relapse to another until almost or quite total 
deafness results, if indeed the patient does not become hope- 
lessly deaf in a few days from the commencement of the 
attack. A few cases taken early have completely recovered. 
It is thought by some (Knapp) that those in the higher walks 
of life, with ample facilities for carrying out treatment, do 
much better than others. This from recorded cases does not 
seem to have been true in a large sense. Whatever treat- 
ment is adopted, most patients will go on to hopeless 
deafness. The best to be hoped for is that the affection 
may be principally of the middle-ear, when a more favor- 
able prognosis can be made. As this matter will often be 
quite difficult to determine with positiveness, a hopeful 
prognosis may be made and treatment persevered in for 
some months. 

Treatment may be directed to any middle-ear symptoms 
which may be present, not forgetting that many authors 
(Sexton, Burnette, Buck, and others) claim that thickening 
of the lining of the tympanum, causing the stapes to be- 
come fixed in the oval window and the membrane of the 
round window thickened, besides other changes which 
seriously interfere with free vibrations and consequently 
simulate nervous affections, may depend on the specificchar- 
acter of the inflammation. These symptoms may often be 
relieved by the sorbefacient power of mercury, so that the , 
middle-ear symptoms may require constitutional treatment 
as well as the nervous symptoms. The principal hope of 
relief to the internal ear will be from the use of mer- 
cury and iodide of potass. Dr. Kipp (1. c), however, 
does not believe in the use of mercury. My own view 
of the matter is, to begin by placing the patient under 
the influence of mercury, in the shortest space of time and 



350 DISEASES OF THE EAR. 

in the most thorough manner, not, however, depressing the 
patient by ptyalism. After this the use of the iodide of 
potass, in large doses, increasing the size of the dose, if no 
amelioration of symptoms appear. Neurologists have 
shown that a basilar meningitis that has resisted ten or 
twenty gr. doses of the iodide of potassium three times a 
day often improve on reaching fifty or sixty grs. To obviate 
the tendency to disturbance of the stomach, the dose may 
be administered with the meals, largely diluted with water, 
and taken in divided portions as wine would be drunk under 
similar circumstances. At all times tonics will be indicated, 
and may even be given during the inunction treatment. 
Troltsch recommends the iodide of ammonium in his text- 
book on the ear (Dr. Roosa's translation). Iodide of iron 
has long been a favorite remedy. Strychnia and electricity 
have been used extensively, but without effect. Most of 
the recent text-books on the ear treat of this subject with 
more or less fulness. 

Since writing the preceding a case has come under my obser- 
vation which illustrates, as far as I know, a new phase of the 
disease under consideration, namely : Papulo tuburcular affec- 
tion of the drum membranes in a subject of hereditary syphilis. 
The case presents the following history : 

A. M. S., aged 18, tall, poorly nourished, has a prominent 
lower jaw ; face and head of the shape of subjects of heredi- 
tary syphilis. His teeth also are badly developed, resembling 
those in hereditary syphilitic cases. He does not admit ever to 
have had syphilis, but does acknowledge a gonorrhoea. About 
four months since he was attacked with an interstitial kera- 
titis, from which he has nearly recovered under constitutional 
treatment, with some of the usual local applications. On July 
18, 1883, after indulging in a somewhat excessive amount of 
beer, his eyes had a serious relapse, and he found that his hear- 
ing had become somewhat affected, the trouble dating back 
about four days. On July 23d, his deafness still continuing, 
the drum membranes were inspected. The right (Fig. 89) 
showed considerable congestion about the short process and 
the manubrium. Along the line of the malleus-handle is a 
whitish-looking appearance resembling softened epidermis, but, 
on attempting to remove it by a bit of cotton, it was found 
firmly adherent. Elsewhere the membrane is somewhat opaque, 
and there is no light spot. The left membrane (Fig. 90) shows 
some redness along the malleus-handle ; light spot present, but 
placed a little above the umbo. Behind and just below the 



HEREDITARY SYPHILITIC AFFECTIONS OF THE EAR. 35 I 

malleus-handle is a triangular grayish mass somewhat re- 
sembling the appearance in the other ear, but more prominent 
and marked. This also can not be removed by the cotton- 




FlG. 89. — S. P., short process ; posteriorly is seen the whitish-looking material described in 
the text. M. P., manubrial plexus of vessels. P. F., posterior fold of the membrana. 
S. P. Q., superior posterior quadrant. 

wool. The hearing of the R. is w. 2^", of the L. w. 4". Bone 
conduction is decidedly better in the left ear. 

July 27M. — Hearing in R. w. 1", in L. w. 3". Bone conduc- 




FiG.90. — S. P., short process ; malleus-handle distinctly seen below. T., tumor. P. W., 
posterior wall. P. F., posterior fold. M. P., manubrial plexus of vessels. A. F., 
anterior fold. A. W., anterior wall. 

tion the same in each ear, although there was some difficulty in 
eliciting intelligent replies. 

August 1st. — Hearing in the R. w. contact, and if4" in L. 
No improvement on inflating the drums ; considerable redness 



352 



DISEASES OF THE EAR. 



about the malleus-handles and short processes in each ear ; 
cornese are clearing, and pain in the eyes yields to atropine. On 
August 3d the whitish spot of infiltrated epidermis has disap- 
peared from the right membrana, leaving the membrane reddened 




Fig. ql — T., tumor. S. P., short process ; the manubrium seen for a little distance. A. F. 



anterior fold. A. W., anterior wall. M. P., manubrial plexus, 
superior quadrant of the membrana. 



P. S. Q., posterior 



and thickened, with a rounded elevation behind and somewhat 
on the manubrium (Fig. 91); hearing as before. In the left (Fig. 
4) the grayish spot has much increased in size, and has a nodu- 




Fig.qz — T. tumor. S. P., short process ; the manubrium may be seen for a portion of its 
course. M. P., manubrium plexus of vessels. P. F., posterior fold. P. W., posterior 
wall. A. W., anterior wall. A. F., anterior fold. 

lar appearance ; hears the w. only on contact. This nodule 
has been present for only two days ; bone conduction about 
the same in each, though the observation is not positive. 



HEREDITARY SYPHILITIC AFFECTIONS OF THE EAR. 353 

6th. — The swelling in the left has decreased in size, and the 
membrana is much more vascular in the region of the tumor. 
The left ear hears the watch on contact, and the right the 
watch pressed. Bone conduction better in left. 

8th. — General condition slightly improved. 

14/& — The lower notes of the piano heard somewhat better 
than the higher ; bone conduction in the right the same as the 
aerial, and in the left somewhat better. 

September 10th. — The vessels on the left membrana surround- 
ing the swelling are much diminished in size (Fig. 93). Eye 
symptoms continue, but with less intensity. Constitutional 
treatment continued. Left hears the watch gently pressed, 
right somewhat less. 

October 10th. — H. D. R. w. iV/ after inflation the same, 




FiG.93. — T., tumor. _ S. P., short process ; nearly the whole of the manubrium is visible. 
M. P., manubrium plexus of vessels. P. F., posterior fold, A. F., anterior fold. 
A. W., anterior wall. 

H. D. L. w. o., after inflation w. pressed. Tuning-fork heard 
better by aerial conduction ; bone conduction somewhat dimi- 
nished ; appearances of membrana unchanged, except that the 
blood-vessels are large and distinct ; ordered to go into the 
country. Three months afterwards, the patient having been in 
the country, the eyes are much better, though not well. The 
drum membranes are looking nearly normal. The H. D. R. is 
w. 2*, L. w. contact, no change by inflation. This has been 
the condition during the whole progress of the case except in 
one or two instances, where the hearing has been slightly im- 
proved by inflation. Tinnitus has hardly been complained of 
at all. Tuning-fork observations the same as in the last 
record. 

I conclude that the tuning-fork tests pointed to a suspicion 



354 DISEASES OF THE EAR. 

of labyrinthine disease, but actual proof of that does not exist. 
The appearance in the right ear has not been minutely de- 
scribed, it being similar to that of the left, only the tumor was 
much smaller, and disappeared sooner. One marked feature 
of the appearance was the great size of the blood-vessels, which 
in the woodcuts are represented by black lines. The engrav- 
ings represent the tumors as grayish or whitish, but after a few 
days the color was a dull red. After the swellings had entirely 
disappeared, vessels of considerable size remained. I infer 
that the tumors were in the dermal layer of the membranes. 
The whitish appearance at the first, I conclude, was due to in- 
filtration of the epidermis, which was soon thrown off. There 
was no evidence of its being a hypertrophy of the epidermis. 
The superficial position of the tumors was evident from the 
facts that the malleus-handles and short processes were dis- 
tinctly behind the tumors, that there was no approach to per- 
foration of the drum membranes, and that the superficial posi- 
tion of the markedly injected blood-vessels indicated that the 
deeper portions of the membranes had escaped. As the der- 
moid layer of the membranes was affected in this process, the 
tumors would come under the head of a skin affection. 

In Bumstead and Taylor on "Venereal Diseases," p. 793, 
in discussing hereditary syphilis these observations are made : 
" These later orders of dermal lesions may be papulo-tuber- 
cular, or perhaps pustular, but in general they are tubercular, 
tuberculo-ulcerous, and gummatous." In the case under con- 
sideration there was no ulceration, no softening, no scaly ap- 
pearance, except the removal at first of the epidermis ; and it 
seems to the writer that in the absence of any literature directly 
bearing upon this subject, we are justified in making the diag- 
nosis of papulo-tubercular affection of the dermal layer of the 
membrana tympani. It is not denied that there was more 
extensive disease than this, there evidently being an inflam- 
mation of the drum cavity with exudation into the tympanal 
lining, including that covering the round and oval windows. 

The evidence of labyrinthine complications was not, per- 
haps, as complete as might be necessary to confirm such a 
diagnosis. It appears to the writer that evidences of laby- 
rinthine complications in syphilitic affections of the middle 
ear are perhaps less frequently observed than is generally 
believed. The illustrations are from pen drawings by Dr. 
J. O. Tansley, of the Manhattan Eye and Ear Hospital, New 
York. 

I am indebted to Dr. Van Allen, of Albany, for a case 



BOILER MAKERS' DEAFNESS. 355 

of syphilitic gumma of the me?nbrana in an unmarried woman, 
set. 20, treated at Dr. Hickock's clinique in the N. Y. Eye 
and Ear Infirmary. She had signs of old iritis, with probably 
gummous deposits in the brain substance or its neighborhood, 
as the patient had a staggering gait, and could not stand 
steadily with the eyes closed, but the tendon reflex was per- 
fect. There was inflammation of the drum cavity, and a 
small perforation of the membrane near the end of the 
manubrium. The tumor was situated behind the extremity 
of the manubrium ; it was about one-fourth the diameter of 
the membrana, and seemed as hard as bone. The patient 
speedily recovered under anti-syphilitic treatment. 

It is not claimed that this case was altogether analagous to 
the one previously reported. In the record it is stated that the 
tumor seemed as hard as bone. It may likely enough have 
been a tumor in the dermoid layer of the drum membrane 
quite similar to my case. The rapid recovery under anti- 
syphilitic treatment would favor this theory. 

THE DEAFNESS OF BOILER-MAKERS, SHIP-CALKERS AND 
OTHERS WHO ARE EXPOSED TO SIMILAR INFLUENCES. 

This affection has long been regarded as principally 
belonging to the internal ear, although latterly a feeling 
seems to be creeping into the minds of aural surgeons 
that middle ear disease may exist as an important compli- 
cation. Roosa, "Diseases of the Ear," fourth edition, p. 509, 
says, " The impairment of hearing is generally attributed to 
some lesion of the labyrinth, probably of the cochlea; for the 
chief symptoms are loss of hearing and tinnitus aurium; 
there is no vertigo or staggering in the gait. Superadded tc 
this serious trouble, tympanic or middle ear catarrh is very 
frequently present, but these must be regarded as purely co 
incidental. Boiler-makers are constantly exposed to sud- 
den and marked changes of temperature, and hence often 
catch cold, intensifying and increasing by this means the 
aural affection." Buck, "Diagnosis and Treatment of the 
Diseases of the Ear," p. 403, regards this affection as in a 
general way labyrinthine, but in some cases he has exam- 
ined he has inferred from the thickened and toughened 
appearance of the memorana that the deafness was owing, 
in part at least, to the great changes in temperature the 
workmen were exposed to He adds, however, that the con- 



356 DISEASES OF THE EAR. 

dition is more likely dependent on the prolonged irritation 
consequent on the concussion of the air upon the drum 
membrane. Burnett, in his "Treatise on the Ear," p. 403, 
says: "Boiler-makers' and telegraph operators' deafness 
may be due as much to nervous exhaustion from continu- 
ous shock as from catarrhal disease, but the latter is gen- 
erally found to have a part in the train of symptoms." In 
the Tr. Amer. Otol. Society, 1882, p. 34, Dr. Holt, of Port- 
land, Maine, gives his experience in the examination of 
forty boiler-makers, and concludes that they had middle-ear 
disease to the exclusion of labyrinth affection, but admitted 
to me in a conversation that labyrinth complications might 
ultimately occur. He observed that if the workman was 
right-handed the left ear would be worse ; on the con- 
trary, if he were left-handed the right ear was the worse. 
The same observation was made of ship-calkers. He con- 
cluded that the violent vibration of the middle ear mechan- 
ism induced by the noise of the hammering was sufficient 
to excite inflammation of the tympanum. Inasmuch as 
these workmen were exposed to great varieties of inclement 
weather and sudden changes in temperature while in a 
perspiring condition, the purely catarrhal influence was an 
important agent in producing the inflammation of the 
middle ear. The evidence of its being principally middle 
ear trouble was as follows: Bone conduction was never in 
a single instance destroyed; the tuning fork when placed on 
the central portion of the head or on the- teeth was always 
heard better in the worse ear; the discrepancy between the 
length of time the tuning fork was heard in the air and 
on the teeth was less than in a healthy ear, that is, hearing 
by bone conduction was comparatively better than that by 
aerial conduction; when both ears were stopped, the tuning 
fork on the teeth was heard about equally on either side and 
for about the same length of time as in the case of ears of 
perfect hearing. No observation was made of the excep- 
tional condition of intermittent bone conduction. In nearly 
every instance there was catarrh of the upper pharyngeal 
space, but the Eustachian tubes were almost always per- 
vious to Valsalva's method of inflation. Holt concluded 
that it was only a matter of time as to whether a boiler- 
maker would ultimately become deaf, especially if he had 
any tendency to catarrhal otitis when entering upon the 
work. Roosa (1. c), p. 510, concludes that those who work 
inside of boilers as riveters lose their hearing completely. 



SECONDARY LABYRINTHINE DISEASE. 357 

As to the management of such cases, it seems that insur- 
mountable difficulties stand in the way of affording any- 
considerable relief. The first indication would seem to be 
to stop the ears so as to diminish the intensity of the sono- 
rous impression. Holt has tried filling the ears with cot- 
ton and found it to be inoperative, for the reason that it 
makes them tender aftera while, and in some cases caused 
excoriations in the meatus. He has also tried ear pads and 
vulcanite ear stoppers, but without success. As the con- 
tact of air to the hearing apparatus seems essential, would 
it not be well to wear covers for the ears made of fine wire 
gauze on the same principle as in its application to hearing 
trumpets where it is desirable to diminish harsh and dis- 
cordant vibrations ? It is well-nigh impossible to make any 
suggestion to prevent the ever operating catarrhal influence 
which seems so potent a factor in developing the affection. 
The labyrinthine disease sooner or later following the 
middle ear affection is mostly secondary to that and does 
not respond to treatment. If the patient is removed from 
the noise and din of the shop before he has become pro- 
foundly deaf, recovery may take place in some cases, and 
in others the disease may remain stationary. 

DISEASE OF THE LABYRINTH DEPENDENT ON MIDDLE-EAR 
AFFECTIONS. 

In acute inflammation of the tympanum there may be a 
simultaneous hyperemia of the labyrinth or it may occur 
some days after the tympanal affection has made its ap- 
pearance. Although it is still a matter of dispute as to 
whether any considerable number of tympanal blood-ves- 
sels supply the labyrinth, there is a sufficiently close anas- 
tamosis of labyrinthine and tympanal vessels to afford a 
ready mode of transmitting inflammatory processes from 
the tympanum to the labyrinth. 

"A serous saturation of the labyrinth" may result from 
hyperemia of this region (Politzer on " Diseases of the Ear," 
English translation, p. 250). In such cases various symp- 
toms pointing to disturbance of function in the labyrinth 
may be noted, together with weakened or abolished bone 
conduction. The ear may become extremely sensitive to 
all sorts of sounds; there may be vertigo, unsteadiness of 
gait, nausea, vomiting, and even convulsions, and yet the 
patient may make a good recovery. Some years since I 



358 DISEASES OF THE EAR. 

had a patient with acute inflammation of the tympanum, 
in which the hearing was nearly nil for the voice, and bone 
conduction was almost obliterated, showing undoubted evi- 
dence of labyrinthine trouble. After two months, however, 
the hearing was almost completely restored. Besides this 
serous saturation of the labyrinth, haemorrhages may 
occur, according to Moos, Archiv. Ophth. and OtoL, Vol. III., 
p. ti8 (Burnett's reference), when the most undoubted 
signs of labyrinthine disease will appear, followed by partial 
or even complete loss of hearing. 

Toynbee, "Diseases of the Ear," English edition, p. 356, 
reports a case where total deafness resulted from a middle 
ear catarrh contracted from sleeping in the open air. It 
was as follows: A farm laborer, set 28, eighteen months 
previous to his call on the doctor slept in an open cart while 
riding during the winter months. Intense pain came on be- 
tween the right temple and ear, which was relieved by ver- 
atrine ointment. About three weeks after this attack, 
deafness made its appearance, at first only for a day or two, 
when it would disappear, but again return. This state con- 
tinued for a few days, when he became totally and perma- 
nently deaf. He complained of loud noises in the head and 
great heaviness and sleepiness; some relief to the head 
symptoms occurred after the drum membranes ruptured and 
the discharge appeared. 

In purulent inflammation of the middle ear in the acute form, 
where the tympanum becomes completely filled with in- 
flammatory products, with considerable swelling of the 
membranes of the labyrinthine fenestras the consequent 
pressure upon the labyrinth may occasionally abolish bone 
conduction and produce great disturbance in the functions 
of the internal ear. It is, however, somewhat temporary 
unless the inflammatory process should reach a high degree 
of intensity, when disorganization of the labyrinth and per- 
manent mischief may result. Sometimes the disturbance 
of function takes on the form of double or false hearing, as 
in a case reported by Roosa, "Diseases of the Ear," fourth 
edition, p. 492. P. A. S., aet 25, a pianist, had an acute sup- 
puration of the right middle ear. In addition to the usual 
symptoms he noticed that in sounding a note on a musical 
instrument that the proper tone was heard by the affected 
ear and simultaneously a tone a half note above was also 
heard, which, however, soon died out, leaving the true tone 
distinctly audible. This symptom lasted about three weeks. 



SECONDARY LABYRINTHINE DISEASE. 359 

In chronic purulent disease of the middle ear the pressure 
from the collected pus may disturb the functions of the 
labyrinth sufficiently to cause a roaring in the ear, nausea, 
giddiness, faintness, dimness of vision, etc., as in a case re- 
ported by Burnett in his " Treatise on the Ear," p. 509. These 
symptoms, however, disappeared in a few minutes. Ac- 
cording to Troltsch " Diseases of the Ear in Children," 
English translation by Green should the pus or inflamma- 
tion in the tympanum breakthrough the delicate structures 
which close the oval and round fenestrae, a direct passage is 
formed into one of these labyrinthine cavities, and the dura 
mater is then only separated from the disease by a thin per- 
forated lamella of bone through which the minutest fibres of 
the nervus acousticus are distributed to the structure of the 
cochlea and vestibule. On page 143 Schwartze is quoted as 
stating that even in the highest degree of inflammation of 
the tympanum it is only exceptionally that a simultaneous 
hyperemia of the labyrinth occurs. According to Schwartze, 
"The Pathological Anatomy of the Ear," English translation, 
secondary inflammation of the labyrinth is found with 
middle ear disease more frequently in the purulent form, 
with or without caries, the labyrinth cavity being filled 
with pus and the membranous structures destroyed. The 
parts are involved through perforation of the labyrinthine 
fenestrae or by a fistula in the labyrinth wall of the tym- 
panum, or even without the existence of any direct com- 
munication with the tympanum. The polypi which so 
frequently accompany a chronic purulent inflammation of 
the tympanum may do serious harm to the labyrinth by 
pressure. When the membrane of the round window is 
pressed upon, there may be loss of power to hear the upper 
notes of the piano, the fibres of Corti which vibrate in unison 
with such notes being located according to Helmholtz, in 
the cochlea, near the round window. 

In scarlet-fever the middle-ear inflammation so often ac- 
companying the fever, as is well known, may be of the 
most serious nature, the labyrinth often becoming involved 
secondarily to the middle-ear disease. Toynbee (1. c), p. 
395, enumerates 98 cases of acquired deaf-mutism where 
scarlet-fever was the cause in thirty-six instances. 

It is not necessary to affirm here that in most cases of 

acquired deaf-mutism that the labyrinth is diseased. 

Ordinarily we have the suppurative form of inflammation 

of the tvmpanum to deal with in scarlatina, but in a case 

'23 



360 DISEASES OF THE EAR. 

reported by Toynbee (1. a), p. 361, it would seem that total 
deafness may result without suppuration of the tympanum. 
The case was that of a man aet. 20. He had an attack of 
scarlet-fever at four years of age; since that time he has 
been totally deaf in his right ear. The membranae were 
observed to be only a little more opaque than natural. 
Toynbee states on p. 399 that " It is clear, therefore, that 
in a majority of cases of deafness from scarlet-fever, the 
effects of very active disease were apparent; this disease 
was usually catarrhal inflammation of the tympanic mucous 
membrane, ending in an ulceration of that membrane, 
which extended to the labyrinth." Field ("Diseases of the 
Ear," p. 249), refers to a girl aet. 10 years who was totally 
deaf from an attack of scarlet-fever when she was two years 
of age. On p. 309 he speaks of scarlet-fever as a cause of 
deaf-mutism, and quotes Hartman to the same effect. 
Troltsch (1. c), p. 158, refers to scarlet-fever as a cause of 
deaf-mutism from labyrinthine complications. Schwartze 
(I. c), p. 161, quotes Moss to the effect that the otitis media of 
several varieties of fever, including scarlet-fever, when of the 
milder varieties, may not go on to suppuration, but may re- 
sult in a small cell infiltration of lymphoid corpuscles in 
the membranous labyrinth. 

Labyrinthine disease resulting from chronic inflammation of 
the tympanum may be developed in a variety of modes. Per- 
haps one of the most persistent and frequent causes of laby- 
rinthine trouble is the long-continued pressure exerted on the 
labyrinth waters, as a consequence of the middle-ear disease. 
This pressure may induce anaemia of the labyrinth, which if 
continued for a sufficient time will result in nutritive changes, 
of the nature of atrophy. 

The mechanism of the pressure is somewhat complex; 
the most frequent condition perhaps is the impaction of the 
foot-plate of the stapes in the oval window from closure 
Of the Eustachian tube and collapsed drum membrane. 
Cicatricial contraction of adhesions within the tympanum 
may draw the membrana inward. Thickening of the mem- 
brane of the round window may cause pressure on the 
labyrinth. At the base of the stapes ossific proliferations 
are often found causing the area of the vestibule to be en- 
croached upon, and which results in pressure upon the 
labyrinth. Politzer states (1. a), p. 246, " the progress of 
the deafness (in adhesive affection of the middle ear) de- 
pends, therefore, principally upon retrogressive alterations 



SECONDARY LABYRINTHINE DISEASE. 361 

(contraction, calcification) which are taking place slowly 
or quickly in the middle ear, and on the participation of 
the labyrinth sooner or later in the diseased process." This 
deafness may, however, only in exceptional cases be abso- 
lute. 

Hinton, in " The Questions of Aural Surgery," p. 235, quotes 
Gruber to this effect: " Gruber lays great stress upon the 
frequency with which labyrinthine affections are secondary 
to tympanic ones, and observes that the secondary nerve 
affections may remain though the tympanic affection dis- 
appears." Hinton makes out a very convincing argument 
to prove the tympanal causation of many labyrinthine af- 
fections, as in a case on p. 259. B. A., set. 42, had signs of 
chronic middle-ear disease. On Nov. 7, 1871, there was 
the usual tuning-fork observation made, which characterized 
middle-ear disease only. On the third of the following 
June, the tuning-fork, instead of being heard better on the 
worse side, was heard better on the better side. In November 
he suddenly fell ill, had nausea and vertigo, but was better 
on the following day. He subsequently had several similar 
attacks, each of which lasted about half an hour. Hinton 
thinks the vertigo, etc., indicated the period at which the 
labyrinth first became involved. 

Inasmuch as all these symptoms may result from tym- 
panal disease alone, the statement does not quite amount 
to proof. Hinton also concludes, from a series of observa- 
tions he had made, that nervous deafness in after life often 
depends on possibly slight and unregarded ear affections 
during childhood or youth. He quotes the case of G. T., 
set. 42, who had gradually lost his hearing at fourteen. Had 
earache as a child; hears some kind of sounds better than 
others. Bone conduction very much diminished. He cites 
the case as an example of labyrinthine disease, depending 
on tympanal disease in childhood. He reports another case 
bearing upon the same point. Miss F. S., aet. 26. At five 
years of age she had a severe earache in the right ear, which 
produced almost total deafness. The clicking of the nails 
could only be heard close to the ear, the voice scarcely 
understood at all; bone conduction gone, even when the 
meatus was closed. He could find no cause for the deafness 
besides the tympanal trouble in childhood. 

Dalby, in "Diseases and Injuries of the Ear," p. 204, 
speaks of a chronic aural catarrh, which in a given case 
has somewhat lowered the hearing. If there is no catarrhal 



362 DISEASES OF THE EAR. 

relapse he thinks the hearing should remain stationary, 
but- "on the accession of some additional circumstance, 
which does not reawaken the catarrh, but without doing 
this, or in any way interfering with the conduction of sound 
to the labyrinth, induces a decrease in the hearing power." 
In such cases he concludes that the labyrinth has become 
involved secondarily, and in consequence of the tympanal 
disease. 

Troltsch on the Ear, Roosa's translation, p. 508, seems 
to hold the opinion that in a case of chronic middle-ear 
disease, with " complete immobility of the ossicula, or cal- 
cification of the fenestra rotunda, that an atrophy of the 
acoustic expansion with retrogressive metamorphosis of 
the fatty or colloid degeneration may occur, as a consequence 
of the deficient specific excitation of the nerve." He also 
agrees with propositions previously laid down, regarding 
the effect of calcified membranae on the integrity of the laby- 
rinth. 

Schwartze (1. c), p. 161, also fully agrees with this propo- 
sition, although he states that " the anatomical proofs of 
this are, however, as yet very few." I have for years no- 
ticed in old cases of chronic aural catarrh, in which the tym- 
panal symptoms showed no signs of activity, that the hearing 
would gradually lower in an unaccountable manner, and 
the bone conduction become weakened. I have no doubt 
but that a considerable number of cases of old otitis, with 
gradual but certain loss of hearing, must be recorded 
as "mixed cases," in which the labyrinth trouble is second- 
ary to and consequent upon the middle-ear affection. I 
believe it is held by most aural surgeons that the deafness 
of boiler-makers, and other affections similar to these, 
depend on a middle followed by an internal ear affec- 
tion. A considerable number of ear diseases, dependent 
on various fevers, are first a tympanal affection, which sub- 
sequently extends to the labyrinth. In all elderly or old 
subjects there is a tendency to atrophic changes in the 
acousticus. Toynbee (1. c.) found atrophy of the acoustic 
nerve thirteen times in subjects between sixty and ninety 
years of age. Politzer states, however (1. c, p. 175), that 
patients of fifty years of age or older often have weak 
bone conduction, without necessarily having disease of the 
ear. 

On the diagnosis of labyrinthine complications. — If one 
ear only is affected, there is usually little or no difficulty 



TUNING-FORK TESTS OF DEAFNESS. 363 

in determining as to whether the functions of the labyrinth 
are disturbed. Naturally, the tuning-fork placed on any 
central point of the head, or on the upper central incisors, 
will be heard better on the affected side if there is no nerve 
trouble. The tuning-fork, by aerial conduction, will usually 
be heard longer than by bone conduction, but not as long 
as in a healthy ear. Closing the ear will increase the dis- 
tinctness and duration of the bone conduction. It is true 
that in some portions of the central line of the skull the 
tuning-fork may not be heard well (Politzer, 1. a), but if it 
is heard in any portion, it is enough for our purpose. 

In a decided case of labyrinthine deafness there is no dif- 
ficulty — the tuning-fork will be heard badly or not at all 
in any part of the central line of the skull or incisor teeth, and 
if there is only a moderate middle-ear deafness remaining, 
the aerial conduction will be more distinct and prolonged 
than by bone conduction. Stopping the affected ear will 
in all cases increase the bone conduction, as well as add to 
the duration of the impression, provided there be any bone 
conduction in the beginning. 

Great care needs to be exercised to discriminate between 
feeling the vibrations and actually hearing them. An un- 
intelligent patient will not respond to the finer tests. In a 
doubtful case the patient is uncertain as to his ability to 
hear better on one side; the tuning-fork may be applied to 
the canine teeth, or even the molars, or to any point on 
the opposite side of the head, or on the mastoid process. 
If he still insists that the opposite ear hears the tuning- 
fork the best, there is no longer any doubt. 

Again, if both ears are stopped by the fingers (not too 
tightly) and both nerves are in a healthy condition there 
will be very little difference in the duration of the hearing 
in each ear, provided that from the affected ear is elimi- 
nated the exceptions of intermittent bone conduction. 

If the bone conduction is weak in a given case, and the 
aerial conductions are considerably stronger, evidence ac- 
cumulates in favor of nervous trouble. It is needless to ob- 
serve that the ear should be placed, by inflation and other 
means, in such a condition that the best hearing for the 
watch, or click of the finger-nails, and voice, may be ob- 
tained previous to the tuning-fork test. 

A large-sized tuning-fork with clamps should be selected, 
as in feeble nerve reaction no impression would be received 
from a small one. 



364 DISEASES OF THE EAR. 

By pushing the clamps towards the opposite extremity 
of the instrument, a great variety of tones may be pro- 
duced, and if any fibres of Corti have become unresponsive, 
this test would elicit that fact. If an exhaustive test be 
applied, the whole range of a piano scale would be required 
to be called into requisition. Where both labyrinths are 
involved the differentiation method of testing will not yield 
results (comparing one with the other). 

The first proposition will be to determine how much of 
the affection is middle ear and how much labyrinthine. 
This is done by noting the difference between the length of 
time and distinctness of the bone conduction, as compared 
with the aerial. As has been before stated, if the aerial 
conduction bears the same or similar ratio to the bone con- 
duction as in the normal ear, it is fair to infer that the 
trouble is mostly labyrinthine. The duration of the hear- 
ing through the bones, as compared to that in the normal 
ear, will give a hint as to the amount of impairment of 
function. Then the principal problem will be, first, to de- 
termine how much the deafness depends on middle-ear 
disease and how much upon labyrinth disease. Second, 
to find whether few or many of Corti's fibres have been in- 
jured by the disease, by noting the degree of perfection 
with which different tones are perceived. The diagnosis 
of labyrinthine disease by other signs is not as certain or 
valuable as with the tuning-fork. 

Vertigo, nausea, vomiting, unsteadiness of gait, etc., be- 
ing sometimes seen in middle-ear disease, are not of very 
great value as diagnostics; neither is sudden and profound 
deafness, as it somewhat infrequently results in this class 
of cases. Improvement of the hearing distance by inflation 
of the tympanum is ordinarily diagnostic of a certain 
amount at least of middle-ear disease, but it does not exclude 
labyrinthine disease, as Politzer has stated (I.e., p. 350) that 
some slight increase or distinctness of the hearing after infla- 
tion often occurs in pure labyrinthine disease. Sometimes by 
stopping both ears with a hearing trumpet, and comparing 
the bone conduction with the aerial conduction in both ears, 
(the tuning-fork being held in the latter instance before the 
funnel of the trumpet) an exact knowledge of the condition 
of the hearing may be obtained. Naturally, by closing 
both ears with the hearing trumpet, the bone conduction 
in each ear is approximated to a similar condition, unless 



DIPLACUSIS. 365 

tuned to 350 vibrations, so that when the 350 vibrations 
reach each cochlea the healthy ear carries the impression 
of these to the sensorium, while the opposite ear only car- 
ries the impression of 300 vibrations, and consequently 
hears the sound just so much lower than its fellow. When 
there is relaxation of the fibres of Corti an opposite con- 
dition exists; that is, the diseased ear would perceive 
sounds of a higher pitch than normal. The result of this 
faulty tuning is to make all musical sounds discordant, and 
very annoying to a trained musical ear. 

There are still other forms of double or false hearing of 
the monauricular variety. The patient finds that the af- 
fected ear at first hears a note at its normal pitch, but di- 
rectly there appears a second sound like an echo, but with 
no perceptible alteration in its pitch. 

Double hearing is caused by some pathological changes in 
the cochlea. No autopsies have revealed what that exact 
condition is. 

Undoubtedly there is frequently intra-labyrinthine pres- 
sure, which in a majority of cases is secondary to middle- 
ear disease. In Wittich's case the double hearing came on 
four weeks after an attack of purulent otitis media, and re- 
mained unchanged in pitch until it disappeared altogether. 
In Knapp's case the double hearing resulted from a suppu- 
rative inflammation of the tympanum caused by the use of 
cold water by means of a nasal douche. Three days after 
the discharge set in the double hearing was noticed. For 
one week after, the pitch of the tone heard in the affected 
ear remained unchanged; but subsequently, and until the 
end of the third week, the pitch was scarcely half a tone 
different from the sound ear, whereas previously it differed 
by two tones. 

In one of Moos' s cases the double hearing seemed to have 
depended for its exciting cause on the administration of 
chloroform, although the patient at the time had a chronic 
middle-ear catarrh. 

Glauert — Berlin. Klin. Wochenschr., No. 48, 1881 (Arch. 
Otol., vol. xi.) — reports a case of monauricular diplacusis 
in which the affection resulted from an acute exudative mid- 
dle-ear disease. All tones from middle " D" up were heard 
double. This disappeared when the ear affection was 
cured. In the Arch. Otol., vol. xi., Moos reports a case, 
translated by Spalding, of double hearing during the ex- 
hibition of iodide of potassium. The patient was a man 40 



366 DISEASES OF THE EAR. 

there is considerably more labyrinthine dicec.se in one ear 
than in the other. 



DOUBLE HEARING PARACUSIS DUPLICATA (MOOs). 

This may be binauricular or monauricular. Knapp (Arch. 
Otol.,vol. i.) defines the affection as diplacusis. The binauric- 
ular variety consists in the hearing of a tone normally with 
one ear, while in the other it is heard one or several tones 
higher or lower. In diplacusis monauricularis the double 
hearing is confined to the affected ear. Thus, as in the person 
of Von Gumpert, quoted by Turnbull from Moos' article in 
the Klinik der Ohrenkrankheit, Wien, 1866, Von G. could 
distinguish the true as well as the false tone in the affected 
ear. The true tone appeared close to him, while the pseudo 
tone seemed several yards away. This was sometimes a 
third, then a fourth, and finally an octave above the nor- 
mal tone. This double hearing also existed for words. 
Von Wittich's famous case in his own person, from the 
Konigsberg Med. Chronicle, vol. iii. (Turnbull's quotation), 
illustrates the condition of binauricular double hearing. 
A tuning-fork placed upon the glabella sounded a half tone 
higher in the affected ear; this was the case, however, with 
moderately high tones only. Knapp's case (1. c.) differed 
from this in the fact that the diseased ear heard the tone 
lower, instead of higher, as in Wittich's case. The explanation 
of this double hearing is best made by Knapp (1. c), although 
it has some similarity to Moos' explanation. It is this: it 
depends upon the faulty tuning of some of the fibres of 
Corti's organ. In certain cases the fibres are too tense, 
vibrating in unison with a tone above that received in the 
normal state, while in other instances they are relaxed, so 
that a number of vibrations fewer than the normal suffice 
to induce sonorous activity. Consequently, when the fibre 
is tuned to a note above its normal pitch it conveys to the 
acoustic centre its own proper note, and the sound per- 
ceived will be lower than that of its normal fellow. To 
illustrate: Suppose a sound of 350 vibrations per second 
is perceived by both ears. The normal ear having a fibre 
which co-vibrates with a sound produced by 350 vibrations 
per second, this impression will be carried to the acous- 
tic centre. But the fellow ear has a fibre of 300 normal 
vibrations per second, and from its morbid tension it is 



DIPLACUSIS. 367 

years of age, who had a nervous asthma but no ear disease. 
For this,gr. x. of potass, iodid. were administered daily for 
about ten days, when, some unpleasant symptoms of iodism 
resulting, the drug was discontinued. 

The double hearing was only for the lower " D" in the 
treble clef, downward to the distance of five notes. This 
continued for three days, the iodide having been discon- 
tinued. There was an iodide exanthema over the shoulders 
and on the extremities, with violent sneezing and excessive 
lachrymation. Moos concludes that a process similar to 
that on the skin was going on in the cochlea, and that mi- 
nute petechia? on the zona pectinata caused an abnormal 
tension which resulted in the double hearing. Little need 
be said regarding treatment. Finding the cause of the trouble 
furnishes sufficient suggestion for treatment. It may be 
worthy of note that diplacusis is rarely or never diagnosti- 
cated in a patient who has not a good musical ear. So far, 
the affection has not been observed in any who could not 
lay a reasonable claim to exactness in appreciating musical 
tones. The two cases herewith reported, one of the mon- 
auricular and the other of the binauricular variety of double- 
hearing, illustrate the nature of the affection. The first case 
is from Dr. Hepburn's practice, the other is from my own. Both 
were those of trained musicians. The Catholic priest was not 
a professional musician, but as is well known the priesthood of 
this church have considerable knowledge of music, incident to 
their calling, and this gentleman had a peculiarly exact 
musical ear. As far as I have observed, these cases make a 
successful recovery. They seem also to confirm the theory 
regarding the function of Corti's organ. 



// Case of Diplacusis Monauricularis in the RigJit Ear. — 
Patient Completely Cured. 

J. P. E., set. 45, while crossing Broadway, N. Y., on Feb- 
ruary 9, 1885, was struck by a stage and knocked down, be- 
coming unconscious. He was conveyed to Chambers Street 
Hospital, where he recovered consciousness in about an hour, 
and was permitted to go home next morning. He had a very 
little bleeding from the ear for twenty-four hours. His prin- 
cipal symptom on reaching home was vertigo, which troubled 
him so much as to interfere with locomotion. He had a ten- 
dency to fall to the right side. He had deafness in the right 
ear, with autophony. He also noticed, on his hearing being 



368 DISEASES OF THE EAR. 

tested by the watch, that he heard the tick double, and could 
distinguish between the true and the false tick, the latter being 
immediately after and apparently further off than the former. 
In testing musical tones, they were heard double for two 
octaves above and below middle C, and he remarked himself 
that with both ears open he could neither sing bass nor tenor ; 
but with the right ear stopped tightly he could discriminate 
perfectly well. Noises approaching him on the affected side 
seemed to come from the occiput around the left side of the 
head and face to the right ear, no matter in what direction the 
noise was approaching. H. D. R. w. 10", H. D. L. w. 18", no 
improvement on inflation. Bone conduction better in left ear. 
The vertigo gradually diminished somewhat, but without relief 
to the double hearing. This condition continued for three 
weeks, at the end of which time an attack of vertigo caused him 
to strike the back of his head violently against a post, causing 
so much pain and soreness that he could not lie down for 
twenty-four hours. He noticed, however, that he no longer 
had double hearing in the right ear. On testing the ears two 
days afterwards I found H. D. R. w. 16", H. D. L. w. 18". T. F. 
(tuning-fork), aerial R. 20" duration, L. 22". T. F. placed on 
teeth, R. 18", L. 18". The vertigo had also disappeared, and 
neither that nor the diplacusis has returned. In short the 
patient says he feels as well as ever, and hears perfectly well, 
and can distinguish musical tones as accurately as formerly, 
when he was a professional singer. 

Diplacusis Binauricularis. — Re suited in Recovery. 

Father C, a Catholic priest, aged 40, has had a chronic catar- 
rhal otitis media in both ears for about two years. The left is 
nearly normal at present, but he occasionally has the Eus- 
tachian tube obstructed ; H. D. R. w. -fa ; after inflation, Jf . 

At the commencement of the attack, the right ear heard a 
given note nearly one tone above that of the left ; after about 
a week of treatment (four visits), the faulty note seemed only 
about a half-tone above its fellow, and after seven visits the 
tone was the same as that of the other ear, except it was 
somewhat muffled. At the time the right ear heard the note 
one-fourth of a tone higher, there was a repetition of the 
first sound, like an echo, which would place this ear per- 
haps in the category of diplacusis monauricularis. 

On the last observation, with the hearing of the right nearly 
reaching ten inches, sounds seemed muffled in this ear, and 



LABYRINTH DISEASE FROM BRAIN AFFECTIONS. 369 

high tones were heard better than lower. Bone conduction 
better in the right ear, although, when both ears are closed, 
the tuning-fork is heard better in the left or good ear. 

At the time the pseudo-note was a half-tone above, thepaiient 
heard only the third and dominant of the chord. 

This patient spent many hours daily in a somewhat damp 
basement of a church in the lower part of the city, giving in- 
struction in a parochial school. Being under orders from his 
superior, he could not spend a sufficient amount of time in the 
more healthful out-door air, he could not take a sufficient 
amount of a proper form of exercise, and he was inclined in a 
general way to neglect himself, as he was devoted to his work 
and felt that any suffering or disease incident to its perform- 
ance was a matter of secondary importance as long as duty was 
faithfully performed. The naso-pharyngeal catarrh which was 
at the bottom of his trouble naturally did badly under these 
drawbacks ; and after being cured of his diplacusis, he discon- 
tinued treatment with the hearing considerably improved, 
although it still failed to remain at the highest attainable point 
after inflation, the analogue of many similar cases. 

DISEASES OF THE ACOUSTICUS AND LABYRINTH DEPENDENT 
ON AFFECTIONS OF THE BRAIN AND ITS MENINGES. 

In hemorrhagic pachymeningitis the nerve becomes involved 
at the inner meatus, the inflammation extending to the in- 
ternal ear; and purulent formations, hemorrhages, organ- 
ized and serous exudations, with pigmentary, fatty, and 
colloid degenerations, occur within the labyrinth which are 
very likely to destroy the hearing. Atrophy of the nervous 
expansion within the labyrinth almost inevitably results, 
unless the parts become wholly destroyed by the purulent 
process. A case reported by Moos in the Arch. Otol., 
vol. ix., well illustrates the subject. It was that of a 
man, set. 49, who died in the Marburg Insane Asylum of a 
hemorrhagic pachymeningitis, and who, after repeated so- 
called paralytic attacks, inside of a year's time had com- 
pletely lost his hearing. The right petrous bone was found 
in the condition usual to purulent middle-ear catarrh, the 
left in that found in simple chronic catarrh. The altera- 
tions in the labyrinth consisted in microscopically demon- 
strable hemorrhages, with numerous transformations of 
the blood into pigment. As a consequence of the hemor- 



3/0 DISEASES OF THE EAR. 

rhages there was inflammation. This led in part to a hy- 
perplasia of the connective-tissue elements, with here and 
there spots of fatty degeneration. Along with this was 
found a partial atrophy of the epithelial tissue and nerve, 
the latter being more highly atrophied, with abundant col- 
loid formation. This atrophy was followed to the ganglion 
cells, and the trunk of the porus. acoust. internus on one 
side up to Rosenthal's canal, and on the other to the ter- 
minal nerve fibres of the crista of the ampullae, etc. He 
showed also the connection between the alterations in the 
labyrinth and those in the intra-cranial process, presenting 
drawings exhibiting the similarity of the alterations in the 
vascular territory of the internal auditory artery, to those 
found in the region of the meningeal artery, as has also 
been described by Kremiansky and Rindfleisch. 

In inflammations of the brain substance or of the meninges, at 
any point, there may be disturbances in the function of the 
labyrinth, as in any event there is likely to be pressure 
upon the sub-arachnoid space, and this, as is well known, 
communicates with the intra-labyrinthine fluids through 
the aqueducts of the vestibule and cochlea. Disease of the 
labyrinth, however, is more likely to result where the cere- 
bral affections involve the base of the brain, whether in the 
immediate region of the acousticus, at the inner meatus or 
more posteriorly, where the nuclei of the auditory nerves 
are placed. A basilar-meningitis, with the formation of 
abscess, is very likely to involve the acousticus, causing in- 
filtration of this nerve with pus cells. The acousticus, from 
its soft and comparatively loose texture, is peculiarly liable 
to inflammatory infiltration. In acute meningitis, accord- 
ing to Politzer (Text Book, Eng. translation), the deafness 
is perceived immediately after the return of consciousness, 
between the third and eighth week of the disease; or it is 
developed more or less rapidly after convalescence. Chil- 
dren are more likely to become quite deaf, with unsteadi- 
ness of gait. In adults there is less likelihood of profound 
deafness, but tinnitus is often a troublesome symptom. 
Deafness in this affection is mentioned somewhat infre- 
quently by authors on general medicine or neurology — 
Watson, Hammond. There is usually no subsequent im- 
provement in the hearing. Sometimes a previous affection 
of the tympanum is aggravated by an attack of meningitis; 
thus Roosa, in his Text-book on the Ear, reports the 
case of a man, aet. 27, who had congestion of the brain, 



LABYRINTH DISEASE FROM BRAIN AFFECTIONS. 37 1 

resulting in hemiplegia of the left side, from which he soon 
recovered. The hearing of the right ear was nil ; of the 
left, Jf. Bone conduction, however, seemed better on the 
right side. Another case from the same author was a man, 
set. 27,' who had an attack of acute basilar meningitis. 
After recovering consciousness the hearing was found to 
be nearly destroyed. Hears the watch laid upon the right 
ear, but not on the left. Tuning-fork heard indistinctly in 
the right. There was a roaring noise in the left ear. An- 
other case from the same author: H. S., a man, had acute 
meningitis and inflammation of the internal ears. He be- 
came totally deaf in one ear, and nearly so in the other. 
Tinnitus and giddiness; H. D. R. watch in contact, left nil. 
Bone conduction only in right. Treated with bromide and 
the iod. of potass, and the constant current. In about five 
weeks the right ear was restored to normal hearing. The 
other ear could, after a time, occasionally hear the ticking 
of the watch. Troltsch states, in his book on diseases of 
the ear in children, translation by J. O. Green, M.D., that 
" hyperemia of the labyrinth is, on the other hand, ob- 
served with hyperaemia and passive congestion within the 
skull, with some of the general febrile diseases, such as 
typhus and acute tuberculosis. . . . Under such circum- 
stances, ecchymosis or even hemorrhage may occur in the 
membranous tissue of the labyrinth." 

A specific basilar meningitis, with or without gummata, 
often enough involves the labyrinth, but this subject has 
been considered under the topic of Syphilitic Affections of 
the Ear. The same remark applies to brain affections, the 
result of traumatism, which see under the head of Fractures 
at the Base of the Brain, Concussions, etc. Deafness from 
cerebro-spihal meningitis will be considered hereafter. Cer- 
tain grave forms of fever, as is well known, result in more 
or less hyperaemia and inflammation of the brain and its 
meninges, this process occasionally extending to the acoustic 
nerves or the labyrinth. The meningitis, which is consequent 
on necrotic or carious bone, has been considered under 
the head of mastoid affections and caries of the petrous 
and squamous portions of the temporal bone. In tuber- 
cular basilar meningitis the inner ear, or auditory nerve, 
is sometimes involved, although affections of the optic 
nerve are more likely to complicate this disease. Lucae, 
quoted by Politzer, reports a case of a boy four years of 
age, who had become totally deaf in the course of a tuber- 



372 DISEASES OF THE EAR. 

cular basilar meningitis. He had hemorrhagic inflammation 
in the semicircular canals and vestibules of both ears. 
Dr. Roosa (1. c.) reports a case as follows: Carrie X., aet. 4, 
had an attack of acute hydrocephalus. On recovery'she 
was found to be deaf; the deafness still continued; there 
was no evidence of disease of the tympanum or pharynx. 

Chronic hydrocephalus sometimes causes profound or total 
deafness, and the first thought arising is, that pressure 
on the brain and nerves, from the effusion, is the ex- 
planation of the loss of hearing. Many cases, however, 
where the head is enormously enlarged and translucent, 
show no defect of the hearing. Speaking of this affection, 
Watson, in his " Practice of Physic," third American edi- 
tion, says: " But far more important effects of the disease 
are those which relate to the three great functions of the 
brain. The child is soon found to be deaf, or dumb, or 
palsied in one or more of his limbs; or idiotic, or all three." 

Apoplexy, whether dependent on haemorrhage into the 
brain substance or any of the cavities within the calvarium, 
or serous effusions (serous apoplexy), or softening of brain 
substance, or fibroid degeneration, is likely to result dis- 
astrously to the organ of hearing, but is by no means cer- 
tain to do so. Naturally, if the apopletic lesion is near the 
acoustic nerve or its origin, it is not difficult to compre- 
hend how extensive lesions of this nerve may result. 
Localized inflammations of brain substance may involve 
the acousticus. According to Moos, Politzer's quotation 
(I.e.), if the haemorrhages occur in the pons and cerebellum 
the ear is more likely to suffer. According to Itard, Op- 
polzer, Andral v. Troltsch and Nothnagel, subjective noises 
are often the forerunners of apoplexy. 

Tumors of the brain have perhaps been sufficiently dis- 
posed of in another portion of this book. It may suffice 
to mention here, that any form of cerebral tumor is capable 
of destroying the hearing by involving the acousticus or its 
origin. If the tumor be malignant, it is quite possible for 
it to penetrate even the petrous portion of the temporal 
bone, as in a case of my own reported elsewhere, and totally 
destroy the hearing. 



DEAFNESS FROM CEREBRO-SPINAL MENINGITIS. 373 



DEAFNESS DEPENDENT ON CEREBRO-SPINAL MENINGITIS. 

This affection is usually regarded as dependent on a 
lesion situated in the labyrinth. It is developed in about 
ten or fifteen per cent of the cases of cerebro-spinal menin- 
gitis. 

It makes its appearance early in the disease — from three 
to fourteen days, but in some cases as late as six months 
from the commencement of the meningitis. In the last 
instance, however, there may be evidence of the presence 
of a previous inflammation of the ear. The deafness may 
be profound in the outset, but often it is only moderate; 
but it is likely to increase to the degree of absolute deaf- 
ness after a few weeks. There is little or no pain, but tin- 
nitus, vertigo, vomiting, great sensitiveness to discordant 
sounds, etc., are quite frequent symptoms. The evidence 
of labyrinthine complications is reasonably good, but in 
some cases not conclusive. Buck, in his " Diagnosis and 
Treatment of Diseases of the Ear," reports a case from Moos 
of absolute deafness from cerebro-spinal meningitis, where 
the labyrinth was perfectly healthy, but the lining of the 
middle ear was intensely congested. It is not necessary to 
demonstrate, in this connection, that middle-ear trouble 
may, in some instances, give apparently all the signs of 
labyrinthine disease. 

The condition of the brain does not seem to have any 
immediate connection with the ear affection, although 
many authors have concluded that an opposite statement 
was the correct one. 

In a general way, if the ear symptoms were dependent 
on the cerebral trouble, evidence of involvement of neigh- 
boring nerves would exist, which is not the case: for in- 
stance, the portio-dura is unaffected, even with its intimate 
connection with the acousticus. There are middle-ear and 
throat complications. A grave form of suppurative otitis 
is not infrequently seen. Absence of middle-ear trouble, 
and the usual symptoms of disturbance of function, 
point undoubtedly to labyrinthine complication. Exactly 
what this condition is, is hardly known, as too few autopsies 
have so far been made to determine what changes have 
been produced. In some cases there is evidence of anaemia 
of the labyrinth, while in others hyperemia seems to be 
present. Dr. Knapp, in the Tr. Amer. Otol. Soc. for 1873, 



374 DISEASES OF THE EAR. 

made the autopsy of a patient who had become deaf from 
cerebro-spinal meningitis. No lesion was found, except 
that one acoustic nerve was softened by suppuration, while 
the facial was apparently normal. The other acoustic 
nerve had not suffered, but numerous pus cells were found 
in the inner auditory canal. Lucae and Heller are quoted 
as having recorded autopsies where the affection under 
consideration exhibited a suppuration in the labyrinth. 
In the Arch. OtoL, Vol. I., N. Y., in a translation by Aub, 
appears the following statement from Moos: "In the 
pathological specimen examined by myself in connection 
with Prof. Luschka . . . consisting of the pons, cere- 
bellum, medulla oblongata, and portion of the spinal column 
of J. Schwartz, we found the acousticus nerve, up to its 
exit from the skull, so completely imbedded in the mass of 
exudation, that Prof. Luschka felt justified in supposing 
that the inflammation and exudation following the course 
of the nerves might easily, in some cases, extend into the 
labyrinth, and thus produce deafness." This specimen 
enabled him to corroborate the fact that the exudation ex- 
tended from the base of the brain, through the hiatus 
Majendie, into the fourth ventricle, and there principally 
covered the striae acousticae. " Adding to this the fact that 
the immersion of the acoustic nerve in exudative masses 
alone may produce deafness, we cannot be astonished at 
the frequency of this symptom in the epidemic cerebro- 
spinal meningitis." 

The autopsy of Case I. of purulent cerebro-spinal menin- 
gitis is as follows: "Fresh haemorrhagic and numerous en- 
cephalitic foci in the brain. Croupous pneumonia of the 
left side; splenic tumor; diffused swelling of the kidneys. 
In both tympanic cavities much pus. In the vestibules nu- 
merous pus cells, a large quantity in the ampullae; the 
cochleae very red, and filled w T ith pus cells. The ves- 
sels of the membranous portion of the lamina spiralis 
much injected; its peripheral half filled with pus, the 
inner half of its surface less so. N.N. Acoust. and. facialis 
of both sides surrounded by pus in the meat, audit, int. . . . 
very few pus-cells were found between the fibres of the 
facialis, while those of the acousticus and its ganglion cells 
were densely surrounded by them. In both nerves the fibres 
were well preserved, the vessels filled to bursting and their 
walls thickened." The next case was similar to this, with 
the addition of dotted ecchymoses in the peripheral portion 



DEAFNESS FROM CEREBRO-SPINAL-MENINGITIS. 375 

of the lamina spiralis. He infers that purulent inflam- 
mation of the inner ear and tympanic cavity may accom- 
pany the disease in question. " We have to deal with a 
well-marked inflammation of the labyrinth. This may 
occur simultaneously with the changes in the meninges of 
the brain and spinal column, or, following the course of 
the neurilemma, it may advance into the labyrinth." It is a 
well-known fact that purulent choroiditis is often a conse- 
quence of cerebro-spinal meningitis. Dr. Knapp con- 
cluded (I.e.) that the anaemia of the labyrinth and inflam- 
mation of the tympanum found in these cases is recovered 
from, but that these are accidental complications, and that 
the affection which leads to permanent loss of hearing con- 
sists of " a homoge7ieous extension of the original morbid process, 
namely, a suppurative inflammation in the labyrinth." He places 
it in the same category with purulent choroiditis and inflam- 
mation of the different joints so often found in cerebro-spinal 
meningitis. It is now a well-known fact, that the arach- 
noid cavity and that containing the peri-lymph and the 
endo-lymph are in free communication with each other, 
and it is easy to see how readily disease may extend 
through these channels of communication. The fact that 
the arachnoid is so frequently found affected in cerebro- 
spiral meningitis, gives color to the theory of extension 
of the morbid process direct to the endo-lymph and peri- 
lymph cavities. Moos, in the Arch. Otol., N. Y., 1881, No. 
4, regards this affection as a neuritis descendens in a ma- 
jority of cases, there being •' a slow encroachment of the 
inflammation from the interior of the cranium into the 
labyrinth, along the peri-neural vessels of the auditory 
nerve." Prof. Lucae, quoted by Burnett in his " Treatise 
on the Ear," found " the hemispheres, base of brain, pons 
and medulla affected by a purulent inflammation of the 
pia mater in a case of cerebro-spinal meningitis. The 
microscopic examination traced the purulent inflammation 
along the auditory nerve to the cochlea. Purulent inflam- 
mation of the sacculi, ampullae, and canals of the mem- 
branous labyrinth was also found; along their vessels were 
masses of pus-cells and free blood-corpuscles; the vessels 
were intensely congested and much thickened; the semi- 
circular canals also showed occasional ecchymoses. The. 
tympanic cavities, except a slight injection, were normal 
The fibres of the facial nerve were subjected to micro- 
scopic examination, but were found to be normal. In the 
24 



376 DISEASES OF THE EAR. 

ampullae and sacculi were here and there deposits of fat 
and chalk." Prof. Lucse concluded that it was probable the 
disease began first in the brain and then passed to the ear. 
In the same article it is stated that Heller found, in a case 
presenting similar disorganizations in the labyrinth, puru- 
lent inflammation of the middle ears. 

So-called Meniere's disease sometimes appears to be laby- 
rinth disease dependent on cerebro-spinal meningitis of so 
slight a type as not always to be recognized. Thus, J. 
Gottstein is reported, in the Am. Journ. Otol., Vol. III., No. 
4, p. 329, as stating that in many of the cases of the neuro- 
pathic form of Meniere's disease the affection depends on 
cerebro-spinal meningitis, the meningitis being overlooked 
on account of its presenting so few noticeable symptoms. 
Many cases of the so-called otitis labyrinthica present the 
clinical picture of a mild cerebro-spinal meningitis, and the 
strongest point of all is, that they occur during an epidemic 
of that disease. He shows by statistics that in places and 
at the time when the cerebro-spinal meningitis was epidemic, 
so-called otitis labyrinthica was frequent, and as the epi- 
demic diminished the cases of this aural disease diminished. 

Buck, on Diseases of the Ear, speaks in a similar manner 
of an epidemic of cerebro-spinal meningitis in New York 
city and parts of Connecticut, where the disease was so 
slight as to be often overlooked, but ear complications were 
frequently noticed. 

Prognosis. — There is great diversity of opinion as to the 
patient's liability to recover the hearing. Some affirm that 
nearly all who are attacked become hopelessly deaf, while 
others make the statement that a large number have the 
hearing partially or completely restored. In the Arch. OtoL, 
N. Y., Vol. I., Moos quotes Dr. Fluegel in the report of an 
epidemic of cerebro-spinal meningitis in the district of Naila, 
where among about 300 cases, five remained deaf, six hard 
of hearing, one deaf and blind, three deaf and unable to 
walk, and one blind in one eye. Dr. Bauer, quoted also by 
Moos (1. a), reports 109 cases of cerebro-spinal meningitis. 
" Hallucinations of hearing were always present, complete 
deafness in seven cases of recovery, and in six of death." In 
the Arch. Otol ', N. Y., 1881, No. IV., in a translation by Dr. 
Spaulding, Moos found 59.3 per cent deaf-mute, 31.4 per cent 
deaf without deaf-mutism, 7.8 per cent permanently hard of 
hearing, while only one patient (1.5 per cent) escaped without 
any subsequent affection of the hearing. I have not seen 



MENIERE'S DISEASE. 377 

much of this disease, but the above figures are more nearly 
in accordance with my experience than other less favorable 
statistics, except that the number of cases having ear com- 
plications is excessively large. 

Where suppurative otitis media is present the patient may 
be profoundly deaf, but subsequently recovers. In such 
cases the suspicion will exist that there was no labyrinthine 
complication, which indeed, under such circumstances, can- 
not be certainly diagnosticated; where extensive purulent 
processes have gone on in the labyrinth, it certainly could 
not be expected that recovery of the hearing would take 
place. 

Treatment, for the most part, is of little avail. Where a 
severe suppurative inflam mation exists, it should be managed 
according to the rules already laid down, with the hope that 
there may be no labyrinthine disease present. In the absence 
of all middle-ear complications, treatment will very infre- 
quently accomplish anything. If simple congestion or in- 
flammation of the labyrinth is suspected, general remedies 
acting on the cerebral circulation may be administered, such 
as pot. brom., ergot, pot. iodid., etc. Later on, if products 
of inflammation exist which may be influenced by sorbe- 
facient remedies, then mercury, iodide of potass., etc., may 
be administered. At a still later stage strychnia and gal- 
vanism may be used, with a view of stimulating diminished 
innervation of the acousticus. It is well enough to perse- 
vere in treatment for a few months after the first attack, as 
a certain number of cases have unexpectedly improved. 
If, however, the deafness is complete from the first, and 
there is no change after one or several months, treatment 
becomes quite hopeless. 



Meniere's disease. 

This is an affection of the labyrinth, generally secondary 
to diseases of the tympanum, the brain or the spinal cord, 
or it may be the result of traumatism. A few cases un- 
doubtedly occur where no other lesion can be detected 
than that of the labyrinth. Meniere held the opinion that 
the affection was principally of the semicircular canals, 
apparently ignoring the fact of cochlear involvment, al- 
though the hearing was very frequently totally abolished, 
and in those cases where it was partially intact, there was 



378 DISEASES OF THE EAR. 

inability to hear certain tones, usually the higher or lower 
tones or both, a fact pointing to impairment of some of the 
fibres of Corti, within the cochlea. This latter observation 
has been much dwelt upon by Knapp, in the Arch. Opthal- 
mology and Otology., Vol. II. Probably the grounds for 
Meniere's opinion were based upon the famous case of the 
young woman who caught cold while menstruating; sud- 
denly she became deaf, with symptoms of extreme vertigo 
and frequent vomiting. She died in five days from the 
commencement of the attack. The autopsy showed a 
bloody, plastic-looking exudation into the semicircular 
canals, a trace of which also was found in the vestibule. 
No other tissue was diseased; the hearing was not carefully 
tested. 

The symptoms of Meniere's disease are so numerous, and 
sometimes contradictory, as to be difficult of adequate and 
lucid, statement. The more frequent manifestations are 
those simulating brain symptoms. The patient is suddenly 
attacked by a vertigo, with or without nausea, and vomit- 
ing, often falling in a faint, although he does not always 
lose consciousness; the face may be pale, and the skin 
bathed in perspiration, the symptoms often resembling 
sea-sickness. The attack may last only a few minutes, or a 
day or two. The vertigo, however, may continue with 
sufficient intensity to keep the patient in bed for several 
weeks. Pains in the back and head are complained of, 
with frequently a benumbed sensation about the latter. A 
sensation of heaviness and depression in the occipito-mas- 
toid region was observed in one of Meniere's cases. 

Tinnitus aurium of a very aggravated character is al- 
most always complained of, and in some instances seems to 
precede the attack. Deafness may be absolute as a conse- 
quence of the first attack, including total abolition of bone 
conduction. In other instances, which are somewhat fre- 
quent, the hearing is lowered, still, however, retaining bone 
conduction, at least for tuning-forks of a medium pitch, 
but at each subsequent attack it becomes still further low- 
ered, until ultimately it is likely to be nearly or quite de- 
stroyed, including bone conduction. Absence of the power 
to hear certain high or low tones has been observed fre- 
quently enough by a large number of surgeons, this being 
a well-known symptom of labyrinthine disease, where the 
cochlea has been invaded. The mind is always clear in the 
more typical forms of Meniere's disease, which serves to 



MENIERE'S DISEASE. 379 

differentiate it from brain affections; moreover, there is no 
disease of cerebral or spinal nerves. Those cases compli- 
cated with brain or spinal disease, are scarcely to be re- 
ceived into the category of Meniere's disease. In falling, 
consequent on the attack, the patient sometimes fractures 
the skull at the base, or destroys the hearing by concus- 
sion, which places the subject rather in the category of 
traumatic diseases of the labyrinth, for an account of 
which, see Index. These cases, however, present many of 
the symptoms of Meniere's disease. 

Cloudiness of -vision, and limitation of the field from 
anaemia of the retina, has been noticed by several ob- 
servers, as Meniere, Moos, Knapp, (1. c.) and others. In 
one case, Knapp noticed signs of atrophy of the optic 
nerve, and he raised the question as to whether the cause 
of the optic nerve trouble was not dependent on a cerebral 
condition, identical with that which might have developed 
the labyrinthine disease. Sometimes objects seem to waver 
before the vision (Meniere). 

The vertigo in Meniere's disease is a most important 
symptom, being, of all the others, the most characteristic. 
The experiments of Flourens, Vulpian, Signol, Goltz, 
Brown-Sequard, and many others, have fairly settled the 
question of the agency of the semicircular canals in the 
production of the vertigo, at least of that form dependent 
on aural diseases. McBride, in the Medical Times and 
Gazette, January 22d and 29th, 1881, (Arch. Otol., Vol. XI), 
claims that there is a cerebral centre, the excitation of 
which produces vertigo. "This centre can be excited by 
influences from the eye, ear, sensorial or visceral, as well as 
central alterations." Any source of irritation to the 
semi-circular canals, undoubtedly is likely to cause ver- 
tigo. It must not be forgotten that any influence which 
increases the intra-auricular pressure, is likely to thus 
irritate the semicircular canals. Nothing is better known 
than the agency of middle-ear disease in causing vertigo, 
through pressure on the labyrinth, and consequent irritation 
of the semicircular canals. Burnett, of Philadelphia, has 
written much on the vertigo, which has its origin in the con- 
dition of a morbid drum-cavity and membrana tympani. He 
relates a case quite at length, where a patient presented the 
symptoms of variable hearing and vertigo, dependent on 
pressure on the labyrinth, the result of collapsed membrana 
tympani, induced by a spasmodic condition of the tensor 



380 DISEASES OF THE EAR. 

tympani. These middle-ear symptoms are often almost 
identical with those of Meniere's disease, but the conse- 
quences to the hearing are not as grave, or as sudden in 
their action, and the bone conduction is not as likely to be 
lowered. Physiologically speaking, however, the general 
disturbance to labyrinthine functions is very similar to that 
found in organic disease of the labyrinth. The nausea and 
vomiting sometimes found in middle-ear disease, may have a 
similar causation to that which occurs in labyrinthine disease; 
namely, irritation of the sympathetic. It seems hardly 
profitable in this place to discuss the question as to whether 
certain semicircular canals are diseased, as evinced by the 
peculiarity of the vertiginous movements; whether circular, 
the patient having a tendency to move about a circle, point- 
ing to disturbance in the horizontal canal, or a tendency to 
move backwards and forwards, or actually to fall, in conse- 
quence of disease of the vertical or the oblique semicircular 
canal, or both of them. 

This vertiginous movement is, next to the deafness, the 
most lasting symptom. According to Nave (Politzer's re- 
ference), the staggering gait has persisted in one instance 
for ten years. 

It seems not to matter what the labyrinthine change may 
be, whether a haemorrhage, an organized exudation, the 
consequences of traumatism, serous. infiltration, hyperaemia, 
etc., as in any event, pressure and consequent irritation of 
the semicircular canals, with vertiginous movements, is 
likely to result. As is well known, the vertigo is aggra- 
vated by closing the eyes, attempting to walk, or to turn 
around, especially if the body has no support. Sometimes 
the symptom is so extreme that the patient cannot lie in 
bed without holding on to the sides of the bed, or supporting 
the head between the hands and looking at a fixed object. 
The vertiginous movement is generally in a direction away 
from the affected ear, although the opposite condition is 
sometimes seen. The tinnitus is very likely to last for the 
remainder of the patient's life, and is often a very distress- 
ing symptom. The deafness is sometimes recovered from 
in certain cases, notably the syphilitic, which indeed hardly 
belong to this category. In a typical case of Meniere's 
disease, that is, the primary labyrinthine affection, without 
involvement of other parts of the ear, or brain, where the 
hearing is once lost, it is rarely or never regained. 

Diagnosis of Meniere's disease. — This is sometimes ex- 



TREATMENT OF MENIERE'S DISEASE. 3 Sl 

tremely difficult. In the typical form of the disease, where 
the patient has no dyscrasia of any kind, no affection of the 
ears, but is suddenly attacked with some or all of the 
Meniere symptoms, as vertigo, nausea, faintness, etc., with 
considerable or complete deafness, accompanied by de- 
fective or abolished bone conduction, the diagnosis of 
Meniere's disease is easily made. In old cases of middle- 
ear affection, in which the tubes are pervious and the mid- 
dle-ear inflammation inactive, with moderate deafness, if 
the patient be suddenly attacked with the Meniere symp- 
toms, grow harder of hearing, with diminished or lost 
bone conduction, it is reasonably certain that there has 
been a sudden exudation into the labyrinth, without any 
connection with the old middle-ear trouble. The symp- 
toms of vertigo, nausea, etc., being often indicative of 
middle-ear trouble, the greatest care needs to be exercised 
to eliminate this source of error in making a diagnosis. 
Where the peculiar Meniere symptoms strongly resemble 
those dependent on brain and spinal-cord disease, it will 
be sufficient to investigate the latter organs, and evidence 
of disease in them will probably show that the ear is un- 
affected. In this instance we may, however, have a some- 
what irregular form of Meniere's disease, secondary to 
brain trouble, which may be difficult to diagnosticate. 
Comparing the hearing after the attack with the amount 
previously possessed, will give a hint as to the nature of 
the trouble. 

Some years since, I had a patient with chronic aural 
catarrh, with considerable diminution of hearing. After a 
while she had symptoms of vertigo; if assisted to rise, she 
would stand by leaning on an attendant, but if she were 
unsupported, would instantly fall. I diagnosticated Me- 
niere's disease, as the tympanum and membrana were not 
in a condition to occasion pressure on the labyrinth and 
thus cause the symptoms. At present I have a child 
under my care who has had mastoid disease, chronic sup- 
puration of the tympanum and polypi. She is now nearly 
convalescent, the mastoid having been operated upon, the 
polypi in the tympanum removed, and the discharge has 
nearly ceased. I infer that there is nothing in the tym- 
panum to press upon the labyrinth. Recently she has 
suddenly fallen several times from an attack of vertigo, and 
I conclude that this is a Meniere symptom. She is too 
young to test the hearing critically. The vertigo of an 



382 DISEASES OF THE EAR. 

epileptic seizure is preceded by an aura, and the hearing is 
unaffected, which is not the case in Meniere's disease. 

Treatment, — In the outset, it may be indicated to 'make 
cold or cooling applications about the head and ears, with 
the view of diminishing any possible hypersemia of the 
labyrinth. This may further be aided by warm baths, or 
even a warm foot-bath, purgatives, leeches about the ears, 
counter-irritation on the mastoid processes, or to the nape 
of the neck. Internally, bromide of potass, may diminish 
the tendency to cerebral hyperaemia, or ergot may be given 
for the same purpose. Later on, a thorough course of 
mercury and iodide of potass, may be given with a view of 
diminishing hyperaemia and absorbing any inflammatory 
products. The iodide of potass, may sometimes be ad- 
ministered in very large doses (a drachm or more three 
times a day) especially if there be any syphilitic taint 
about the patient. To still further aid absorption, Politzer 
(Text-book, English translation) recommends the daily 
subcutaneous injection of 4 to 10 drops of a 2 per cent 
solution of the muriate of pilocarpine, after the second or 
third week, when the more acute symptoms have subsided. 

For the vertigo it is well to keep the patient in bed, his 
head somewhat elevated, and something near at hand for 
him to take hold of if necessary. Sometimes holding the 
head between the hands and fixing the eyes on a given 
object will serve to diminish the vertiginous sensation. 
Where there is very annoying tinnitus and vertigo, Char- 
cot's method of administering quinine promises some 
hope of relief. It may be given in daily doses of from ten 
to sixteen grains for three or four weeks, and should at first 
apparently aggravate the tinnitus. At the end of this 
period it may be interrupted for fifteen days, then again 
commenced. This may be repeated a third time if neces- 
sary ( Arch. Oto/., Vol. XL). It is well not to push the ex- 
citant effects of the quinine too far. A drachm of dilute 
hydrobromic acid in a tumbler of water I have occasionally 
found serviceable in relieving the tinnitus. It may be 
repeated daily, or oftener if necessary. I do not know that 
its effect is more than temporary. I have nothing to 
say favorably of electricity. By any method whatever, in- 
cluding Brenner's formula, it seems to have no influence in 
alleviating the symptoms. 

In certain cases where there is a doubt about the diag- 
nosis, means may be used to better the condition of the 



TREATMENT OF MENIERE'S DISEASE. 383 

membrana tympani and middle ear. By Siegle's otoscope 
the air may be rarified in the meatus, and the membrana 
drawn outward, and possibly the tinnitus and giddiness 
may be relieved, or division of the posterior fold of the 
membrana may be done if there is any evidence of contrac- 
tion of the membrane, and consequent pressure on the oval 
window. The subjoined cases are herewith inserted, as illus- 
trative of a few of the many phases characterizing the affection 
under consideration. It will be readily seen that the so-called 
Meniere's disease represents a group of symptoms rather than 
a well-defined pathological condition ; but it is, none the less, a 
convenient mode of classifying symptoms which could not be 
disposed of as well under another heading. 

A Case of Meniere's Disease, Uncomplicated. 

John Caffrey, aet. 30, came to the Manhattan Eye and Ear 
Hospital on account of deafness, which came on suddenly six 
weeks previously. He stated that he had eaten some oysters 
at a restaurant, which had resulted in nausea and vomiting. 
There was considerable vomiting, and he was confined to his 
bed for a week ; his right side was paralyzed, and the vision of 
the right eye was nil. The deafness came on during this attack. 
On admission his vision was found to be perfect, but there was 
marked unsteadiness of gait. The hearing of the right ear 
was : finger-nails, one half inch. Left slightly better. Dr. 
Amidon, of the Nervous Department, found no ataxic symp- 
toms, and was inclined to suspect haemorrhage into, or inflam- 
mation of, the semi-circular canals. Bone conduction was en- 
tirely abolished in the right ear, and was very feeble in the left. 
The appearances of the drum membranes were those of chronic 
catarrh. With the view that the disease might be an exudative 
inflammation involving the nerve center of the acousticus, or 
its distribution in the labyrinth, ten drops of a saturated 
solution of iodide of potassium three times a day was ordered. 
On April 2d (one week after entrance), the hearing had in- 
creased for the finger-nails, a half-inch in the right ear, and a 
little more in the left. On April 9th, hearing the same in the 
right, but still further improved in the left. The iodide was 
increased to twenty drops three times a day, with additional 
drops from day to day, as it could be borne. May 21st : has 
reported occasionally up to date. Right hearing unchanged ; 
left hears finger-nails at three inches ; vertigo nearly gone ; 
walks fairly well. Bone conduction still absent in right, and 



384 DISEASES OF THE EAR. 

somewhat improved in left. Has noticed improvement in the 
hearing as well as in locomotion. Pot. iodid. increased to fifty 
drops three times a day without suffering inconvenience. Can 
now hear loud conversation, which he hardly could do at first, 
and he feels anxious to continue treatment. 

Meniere's Disease, Complicated With Middle Ear Trouble. 

Frank Doherty, set. 42, was brought to me for a consultation 
by his physician on October 3, 1884. The right ear has old 
middle ear trouble of five or six years' duration. He had tin- 
nitus and hardness of hearing for two months, when he sud- 
denly heard perfectly (?), but the tinnitus partially remained, 
and exists at this time. On May 22, 1884, he took a tepid 
bath, and on the same night he became dizzy and vomited ; 
the tinnitus was worse than ever before. At the present he 
hears a little better. In the first of the attack the dizziness 
lasted two or three weeks. The vomiting only continued a 
couple of days (that is, occasionally during this time). The 
tinnitus was never in the left ear. He is not as firm on his 
feet as he was, and is a little nervous. In the right ear a loud 
voice is heard at six inches ; in the left three inches. Tuning- 
fork heard by bone conduction with difficulty in either ear, but 
better in the right. Similar observation for the aerial conduc- 
tion ; appearance of membranes does not explain the profound 
deafness. He is still unsteady in the legs, but can turn around 
with his eyes shut without stumbling. Inflation slightly im- 
proves the left ear. Ordered hydrobromic acid for the tinnitus. 

Some of the points in this case seem obscure. The expres- 
sion that he heard perfectly after having hardness of hearing 
and tinnitus for two months, especially as the tinnitus did not 
disappear, seems incredible. It would appear that the tepid 
bath brought on the attack of dizziness, vomiting and aggra- 
vated tinnitus, and well may be believed to be due to minute 
capillary hemorrhages within the labyrinth, probably affecting 
the cochlea on account of the great deafness, and also the 
region of the semi-circular canals, from the disturbed coordina- 
tion. Even this fine theorizing is unnecessary, for the simple 
state of intralabyrinthine pressure from exudations is sufficient 
to cause these symptoms. Extensive changes in the labyrinth 
could not have resulted, as the hearing was far from being 
abolished. The evidence of labyrinthine complication appears 
from the fact of better bone conduction in the better ear, 
together with the maintenance of a nearly normal ratio between 
aereal and bone conduction. 



LABYRINTHINE DISEASE FROM TRAUMATISM. 385 

To those who desire still further to study the subject of 
Meniere's symptoms, I would state that Knapp, in the 
Arch. Otol., Vol. II., has a very exhaustive article on the 
subject with cases, including a transcription of Meniere's 
original ones, and the literature of the subject fully re- 
ported to date. J. Gottstein in the Arch. f. Ohrenheilk. 
Bd. XVII., has an article on the neuropathic form of Me- 
niere's disease. There is also a thesis for the degree of 
Doctor of Medicine, on this subject, by Palasne de Cham- 
peaux, Paris, February 24, i88t. In the Am. Jour. Otol., 
July, 1881, is an article bearing somewhat on this subject by 
H. N. Spencer, M.D. " Giddiness and Middle Ear Disease." 
McBride, " Etiology of Vertigo," "Med. Times and Gazette," 
January, 1881. Bonnafort : "Some pathological conditions 
of the tympanic cavity, which give rise to nervous symptoms, 
ascribed by Flourens and Goltz as belonging exclusively to 
the semicircular canals." Comptes rendus de l'Acad. des 
sciences, November 3, 1879, on Meniere's disease. A. Guye 
of Amsterdam (translated by Spalding), in Arch. Otol. Vol. 
IX., C. Fere et A. Dumais, " Note sur la Maladie de Me- 
niere, et en particulier sur son traitment par la methode de 
M. Charcot," Rev. de Med., 1881. G. Brunner, on " Vertigo 
in Affections of the Ear," Arch. Otol., Vol. II., No. 1, pp. 
283-342, besides a number of other authors. 



CERTAIN AFFECTIONS OF THE LABYRINTH AND TYMPANUM 
DEPENDENT ON TRAUMATISM. 

The first and most important injury is that of fracture at 
the base of the skull. From the nature of things, this in- 
volves some portion of the temporal bone, in which is 
placed the organ of hearing. The most frequent direction 
of the fracture is through the petrous portion of the tem- 
poral bone, where it is hollowed out to make room for the 
auditory nerve at the inner meatus, and the cavities for 
the reception of the vestibule, semicircular canals, cochlea, 



386 DISEASES OF THE EAR. 

and in adults, the tympanum. A single fracture, therefore, 
may involve the whole of the essential organ of hearing. 
It is hardly necessary to allude to the manner in which 
such fractures take place; direct violence upon any part of 
the skull by almost any conceivable method may be an 
adequate cause. 

A fall, where the patient strikes on his feet, may, by a 
co?itra-coip, fracture the base of the skull in the region of 
the foramen magnum. A blow on one side of the head 
may produce a fracture of the opposite petrous portion by 
a contra- coup. It is scarcely necessary to go into detail in 
the explanation of the manner in which the labyrinth is 
injured. Hemorrhage into the labyrinth, inflammation, 
either purulent or proliferating, may ensue. Escape of cere- 
brospinal fluid or labyrinth waters, with rupture or com- 
plete disintegration of delicate labyrinthine structures are 
some of the more frequent consequences of this form of frac- 
ture. 

There are few if any exceptions to the rule that total 
deafness sooner or later results from fracture of the petrous 
portion of the temporal bone. 

The symptoms of fracture of the petrous portion of the 
temporal bone are as follows: if the patient has received a 
severe blow on the head from a fall or by any other means, 
he may or may not remain unconscious for a few hours or 
a day or two. There may be vomiting and involuntary 
evacuations; delirium and convulsions, accompanied by 
alteration in the size of the pupil, with or without intoler- 
ance of light, may be present. Other signs of inflamma- 
tion of the brain may speedily follow, notably a febrile con- 
dition. Pain in the head is quite a constant symptom, and 
is often very severe, together with a peculiar sensation of 
feeling "wrong in the head." Numbness about the head 
and face is sometimes complained of. Often the patient 
has a feeling that the head is of great weight. Chills are 
sometimes complained of. Vertigo is a very constant symp- 
tom, and may continue long after the patient is otherwise 
convalescent. The latter symptom is often accompanied 
by so great a degree of incoordination as to make walk- 
ing impossible. Tinnitus is almost always a symptom, and 
is very persistent. Profound deafness usually results, from 
which few or none recover. The patient is often ill in bed 
for a number of w T eeks, but occasionally he is able to keep 
about his work in a somewhat unsteadv manner. The 



LABYRINTHINE DISEASE FROM TRAUMATISM. 387 

pain about the head and ear is sometimes aggravated by 
blowing the nose, swallowing, or by any movement of the 
jaw. If only one side be affected, the patient finds it more 
agreeable to lie on the opposite side. In a few cases there 
may be most of the signs of a purulent inflammation of 
the tympanum after a few days have elapsed. 

Some of the physical signs are: bleeding and a watery 
discharge from the meatus, nose, or throat. The hemor- 
rhage from the meatus, characteristic of fracture of the pet- 
rous portion, is considerable in quantity, and continues for 
some days. A fracture involving the region of the tym- 
panum and osseous meatus does not admit of excessive or 
long-continued bleeding; moreover, the blood is likely to 
be arterial in quality, coming largely from the tympanic 
artery (Buck), while the hemorrhage from fracture of the 
petrous portion is likely to involve some of the venous 
sinuses. If the membrana is not involved in the fracture, 
the blood may be poured into the tympanum and dis- 
charged from the throat or nose. The serous-looking dis- 
charge is usually thought to be identical with the cerebro- 
spinal fluid, although, as there is a communication between 
the labyrinthine fluids and those of the subarachnoid space, 
this point is not certainly determined. Often the serous 
discharge may only be from the labyrinth. It must, how- 
ever, be excessive in quantity and continued for some 
days to be an evidence of fracture of the petrous portion. 
When the tympanic walls and those of the osseous meatus 
only are fractured, there may be a discharge of bloody 
serum from the serous otitis media, which is often the re- 
sult of the injury. In some instances this tympanal dis- 
charge may be excessive in quantity. The cerebro-spinal 
fluid may be distinguished from the serum, the result of a 
middle-ear inflammation, by the fact that the former contains 
double the quantity of chloride of sodium that is found in 
serum, and only a trace of albumen, so as not to be coagu- 
lable by heat and nitric acid. As is well known, serum con- 
tains a certain amount of albumen, which causes a per- 
ceptible coagulation on the application of heat and nitric 
acid. 

On inspection of the auditory canal and meatus evidence usu- 
ally exists, though not always, of the injury. The mem- 
brana tympani will frequently be found ruptured, more 
frequently in the upper anterior portion. As the fracture 
so frequently extends along the osseous meatus through 



388 DISEASES OF THE EAR. 

the Glasserian fissure, a rupture of the soft parts of the 
meatus may be seen at that point, or there may only be a 
minute spot where blood is seen oozing. The meatus may 
be filled with blood-clots. The membrana, besides a rup- 
ture, may have blebs projecting from its surface, filled with 
blood (Buck). The serous discharge will generally be 
tinged with blood, whether it comes from the tympanum, 
labyrinth, or intra-cranial cavity. If there has been any 
considerable solution of continuity in the meatus or tym- 
panum, granulations may be developed, requiring atten- 
tion. 

Fractures of the osseous meatus extending to the tympanum may 
not destroy the hearing, as several of Buck's cases (1. c.) 
show. A case also reported in the Am. Joicr. OtoL, Vol. III., 
No. 2, points in the same direction. It occurred in the 
wards of George Buchanan, in the Glasgow Hospital. The 
patient was a man, who fell a distance of twenty feet, and 
an iron column upon which he was at work, fell upon him, 
striking him on the head. There was pain in the right 
temporal region; he was stupid, and bled from the right ear 
and posterior nares; a watery fluid was mixed with the 
flow of blood from the ear. There was facial paralysis of 
the right side and impairment of hearing of the same ear. 
The haemorrhage from the ear continued for two days. 
The ear continued to discharge a transparent yellowish fluid 
for about six weeks, when this became purulent and grad- 
ually ceased under the use of astringents. 

In this case the serous-looking discharge was from the 
middle ear, the result of inflammation, and the patient 
made a good recovery. The paralysis of the facialis was 
probably due to a fracture of the bony wall of the hiatus 
Fallopii. Another case, from Mr. Walmsley, in the London 
Lancet, Oct., 9th, 1880 {Am. Jour. OtoL, Vol.' III., No. 2). A 
boy, aet. 6, fell from a swing, striking his head. He was 
brought to the hospital in an unconscious condition. There 
vras copious bleeding from the ear, with facial paralysis of 
the same side. On the following day consciousness returnd 
but he remained somewat stupid for several days longer. 
The profuse serous discharge from the ear ceased on the 
second day, and on the sixth the child was bright and 
sharp. Five weeks later he left the hospital perfectly well, 
excepting some facial paralysis. Hearing not affected by 
the injury. 

Some of the reported cases of fracture about the base of 



LABYRINTHINE DISEASE FROM TRAUMATISM. 389 

the skull show that the hearing was not impaired until some 
days after the injury, the deafness seeming to result from 
the inflammation following the injury. Again, falls on the 
head have produced sudden or subsequent deafness, with- 
out evidence of fracture. These may be explained by, first: 
Shock to the acoustic nerve from the concussion; and sec- 
ondly, from the basilar inflammation resulting from the 
blow {vide Buck's cases, 1. a). A patient at the Manhattan Eye 
and Ear Hospital, under the care of Dr. Tansley, was rendered 
totally deaf by falling downstairs. Dr. Seguine concluded that 
the acoustic nerves, on account of their great softness, had be- 
come ruptured at the internal meatus from the force of the fall. 

Any penetrating wound of the tympanum, when the labyrinth 
has been opened or encroached upon, may spoil the hear- 
ing, especially if the liquor Cotunnii is evacuated. Buck 
(1. c.) reports a case where a negro, with suicidal intent, 
fired a pistol, first into one ear, then into the other, without 
destroying life, but abolishing the hearing. Pieces of bul- 
let were removed from the right ear. The left ear contained 
no shot, and the Doctor concluded that it had been previ- 
ously removed. Pieces of dead bone were removed from 
the meatus, granulations and polypi resulted from the vio- 
lent suppurative inflammation following the injury. 

The following case, by Prof. Holmes, of Chicago, illus- 
trates one of the phases of traumatism of the tympanum 
and labyrinth. It is from the Tr. Internat. Otol. Soc, 1876. 
Mr. T., set. 43, in 187 1 accidentally thrust a penholder into 
his right ear. It caused great pain, which subsided after a 
few hours, but there was for ten days great dizziness, tin- 
nitus and total deafness. Subsequently riding in the cars 
caused a return of the vertigo, which became so great that he 
could scarcely walk with safety. For five months this diz- 
ziness increased, so that he had to give up business. At this 
time the Doctor first saw him ; he was in good general health, 
and there were no objective signs of inflammation about the 
ear. Just behind the centre of the membrana was what 
seemed a minute cicatrix. Ear totally deaf. Eustachian 
tubes normally pervious. The vertigo had increased to a 
wonderful degree; the slightest motion of the head produced 
a sensation of falling forward, as though he was making a 
somersault, and he had to grasp his chair to prevent fall- 
ing. While lying on his back in bed, he had to grasp the 
side of the bed and keep his head absolutely motionless. The 
bed seemed to whirl rapidly forward. There was at times 



39° DISEASES OF THE EAR. 

considerable nausea, and an unpleasant sensation about 
the head. By holding the head with both hands, it could 
be moved slowly. For some time the patient had taken 
pot. iodid., pot. bromid., hyd. bichlorid., diuretics and 
cathartics. Blisters and galvanism had been applied over 
the mastoid. The violent symptoms continued about three 
weeks, when they began slowly to disappear. Remedies did 
not seem to have contributed to his relief. After a few 
months he was able to take a voyage to Europe; the vertigo 
and tinnitus were slightly troublesome. Two and a half 
years after this there was very little tinnitus; the ear showed 
subjectively no signs of disease. On bending the head low 
and suddenly raising it, there was slight vertigo. Deafness 
of right ear complete. 

A few indications for treatment present themselves. Most 
of these have been already hinted at in the previous recital 
of cases and symptoms. When there is considerable in- 
flammation of the tympanum, leeches may be necessary, as 
in ordinary acute inflammation, with the warm applications, 
anodynes, and opiates appropriate to the management of 
that affection. Any foreign substance maybe removed by 
means already suggested. (See Foreign Bodies in the Me- 
atus). Granulations and polypi maybe treated in the usual 
manner. 

Any head symptoms may receive appropriate treatment, 
and the febrile symptoms be met in the usual manner. 
When there is great shock to the system, alcoholic stimu- 
lation or ammonia may be needed. At a later stage mer- 
cury may be given to dispose of any products which may 
be strangulating nerve filaments in the labyrinth. Some- 
times large doses of iodide of potash may successfully 
appeal to any inflammatory symptoms at the base of the 
brain. I have said nothing about the prognosis as far as 
the life of the patient is concerned. Naturally many of the 
more serious fractures at the base of the brain destroy life 
by the purulent meningitis which so often results.. 

PRIMARY ACUTE INFLAMMATION OF THE MEMBRANOUS 
LABYRINTH. 

Voltolini claims that such a disease as Primary Acute In- 
flammation of the Membranous Labyrinth exists (Monatsch. f. 
Ohrenheilk. V. 9, Blake s Reference). The symptoms are as 
follows : the disease attacks only children who appear to be 
in perfect health, with no ear trouble ; suddenly they are 



LABYRINTHINE DISEASE FROM TRAUMATISM. 391 

stricken down with a fever, chills, delirium, vomiting, ver- 
tigo, loss of consciousness, convulsions, face very red and 
inflamed, and pain in the head. Profound or absolute 
deafness comes on in one or two days from the commence- 
ment of the attack. The duration of these symptoms is 
only a few days, something less than a week, and in some 
instances a little longer. No lesion whatever seems left be- 
hind, except the hopeless deafness and the staggering gait; 
the latter may remain for some time. The intelligence is 
never affected in this disease, and no cranial nerves are in- 
volved. The disease much resembles a meningitis, but it is 
too brief in its duration, as the latter ordinarily continues 
for several weeks. Absence of lesion of any of the cranial 
nerves except that of the acousticus is relied upon by Vol- 
tolini to prove that there is no central disease. According 
to him this affection never destroys life; this point being 
an apparent refutation of the idea of its being associated 
with brain disease. It may strike the observer that this af- 
fection resembles in some respects the more typical forms 
of Meniere's disease — both attacking the patient suddenly, 
the intellect unaffected in each, and profound or total deaf- 
ness the result in both. Moreover, in each disease no cause 
has been discovered for the sudden development of the 
symptoms. J. Gottstein, in the Arch. Otol., Vol. X., p. 81 (Re- 
view), and Arch. Otol., Vol. IX., p. 254 et seq. (translation by 
Spaulding), raises the question, with some apparent success, 
that Voltolini's cases are, many of them, only mild attacks of 
cerebro-spinal meningitis, which he denominates as one of 
the neuropathic forms of the Meniere group of symptoms. 
He illustrates this by a case, as follows: H. K., aet. 15, was 
suddenly attacked, Feb. nth, 1879, with fever, violent head- 
ache, vomiting, and pain in his limbs. He lay in an apo- 
plectic condition, and ate nothing. This state lasted one 
day. Late at night the child recovered consciousness and 
found that he was totally deaf. 

On Feb. 21st sensorium clear, no fever, the patient being 
very weak. He only had moderate headache, and a dread- 
ful roaring in both ears; on leaving his bed he staggered 
so much as to require to be led. No other signs of dis- 
ease of the ears. He recovered very gradually, but his 
gait was uncertain in the dark for several months. Deaf- 
ness seemed absolute. Buck (Diagnosis and Treatment of 
Ear Diseases), evidently follows in the same line, when, in 
speaking of one of the forms of Meniere's disease, he con- 
cludes that in young subjects the symptoms often depend 
on a mild attack of epidemic cerebro-spinal meningitis. 
25 



392 DISEASES OF THE EAR. 

eludes that in young subjects the symptoms often depend on a 
mild attack of epidemic cerebro-spinal meningitis. 

He cites a case bearing on this point thus : 

A girl about fourteen years of age was suddenly taken 
ill with dizziness, tinnitus, slight disturbance in the vision, 
photophobia, and finally vomiting. Two days after, she was 
very deaf, and during the same day this increased to apparently 
total deafness. The other symptoms soon disappeared, but the 
deafness and inability to maintain her equilibrium persisted for 
at least three months afterwards. The middle ears were prac- 
tically normal. As all these cases seem not amenable to treat- 
ment nothing is suggested. 

DEAFNESS DEPENDENT UPON SCLEROSIS OF THE POSTERIOR 
COLUMNS OF THE SPINAL CORD. 

This occurs with considerable frequency, accompanied by 
affections of the nerves in the vicinity of the acousticus, 
more especially the second, third, fifth and sixth nerves. 
The sight is consequently frequently affected. The im- 
pairment of hearing is usually on both sides, but one ear 
may be more affected than the other. It may go on to pro- 
found deafness, but it often stops short of it. There may be 
tinnitus, but it is frequently absent. 

It is somewhat uncertain what the exact change in the 
acoustic nerve consists in; probably something similar to 
that which takes place in the posterior columns of the cord. 
Erb, Ziemssen's Handbuch, p. 142, states that in some cases 
of tabes he found definite atrophy of the auditory nerve to 
be the cause of progressive deafness, together with "dis- 
seminated sclerosis" (A. f. O. ii.). Could find no change in 
the auditory nerve in gray degeneration of the spinal cord 
(Politzer's Reference, p 725). 

Thomas Buzzard, of London, in the Lancet, Sept. 24th, 
1881, quotes Duchene, Bemak, Tobinard, and others, as 
having already pointed out that the acoustic nerve may 
also be affected in tabes dorsalis, but no one suspected the 
frequency of this complication until Pierrot called attention 
to it. 

Since then McBride has found a greater or less degree 
of deafness, though sometimes only transitory in its ap- 
pearance, in every case that came under his observation. 
Ormerod observed this symptom in five out of a total of 
thirteen cases. 

McBride thinks it possible that the affection of the acous- 



DEAFNESS FROM TABES DORSALIS. 393 

ticus may in some cases be a leading symptom, just as in 
others the optic nerve may be affected, and he presumes 
that certain cases of "nervous deafness" may be accounted 
for by the presence of tabes dorsalis. (Archiv. Otol., XI., No. 
2). J. Gottstein in the Arch. Otol., Vov. IX., No. 3, in 
speaking of Case V., just reported, thinks the affection in 
the ear should be connected with the symptoms of tabes 
which were present. He states that disturbances of hearing 
are rare, in cases of tabes, in comparison with those of sight. 
He quotes Eulenberg as having seen four cases of disturb- 
ance of hearing in sixty-four cases of tabes. 

Gottstein does not believe the labyrinth to be the seat 
of the disease, but that the auditory nerve is "affected in 
the anatomical process of tabes," and that in Case No. V. the 
nerve was affected at its central origin, on account of the 
suddenness of the attack and the complete deafness result- 
ing in both sides. 

The following case is a good illustration of this affec- 
tion. He came under my care at the hospital. 

P. J. C, set. 38; was formerly a policeman; has most of 
the symptoms of multiple sclerosis of the posterior columns 
of the spinal cord. Among them are diminished sight, con- 
tracted pupils, great deafness and extreme difficulty in walk 
ing, from the usual incoordination of locomotor ataxy. He 
is unable to walk with his eyes closed, without great danger 
of falling. His vision is j~[j- in each eye; the fields are both 
considerably diminished concentrically (about 6o° in the 
right eye, and a little more in the left); signs of atrophy of 
the nerve and choroid; pupils about the size of a pin hole. 

The ear affection came on at about the time the sight was 
noticed to fail (about three months ago) and the hearing is 
growing worse. The hearing distance of the left ear is, click- 
ing of finger nails at contact; shouting not heard. The 
tuning-fork heard close to the ear for eight seconds, but 
bone conduction is entirely absent. In the right ear the 
voice could be heard at one foot, if considerably elevated. 
Click of finger nails heard three fourths of an inch; slight 
improvement on inflation. Inflation does not improve the 
hearing of the left ear. The tuning-fork against the 
teeth was heard for 17 seconds in the right ear; by serial 
conduction, eight seconds; on the mastoid of the same side 
it was heard twelve seconds. There were signs of old ca- 
tarrhal otitis in both ears. The right ear seemed to be some- 
what of a mixed case, but the left showed unmistakable evi- 



394 DISEASES OF THE EAR. 

dences of labyrinthine trouble. Galvanism was tried 
without effect. 



DEAFNESS FROM SUNSTROKE. 

This is undoubtedly a rare affection. I find only occa- 
sional mention of it in literature. In Roosa's Treatise on 
the Diseases of the Ear, fourth edition, p. 536, is a case of 
deafness with effusion about the acoustic nerve. There 
were epileptic seizures. The patient recovered his hearing. 
Among other possible causes of the difficulty was men- 
tioned sunstroke, but without enlarging on the subject. In 
the somewhat various cerebral conditions incident to sun- 
stroke, it is not difficult to imagine changes occurring in 
the nerve or labyrinth. The following case seems to have 
at least been aggravated by the attack of sunstroke, but I 
am by no means certain that it was the principal item in 
the pathogenesis of the deafness. I am indebted to Dr. 
N. J. Hepburn, of the Manhattan Eye and Ear Hospital, for 
the case. It is as follows: T. F., aet. 37, laborer. Deafness 
in the right ear dating back four years, at which time he 
had a sunstroke. While working in the sun, he suddenly 
became dizzy and fell. He was taken to the police station, 
where he lay unconscious for two and half hours. He was 
not treated, and was able to return to his work at the expi- 
ration of one week. On reaching home on the day of the 
sunstroke he found that he could not hear with his right ear. 
There was also tinnitus; no history of syphilis. He came 
at the present time for treatment, as he is growing hard of 
hearing in his left ear. The Hearing Distance Right, is 
watch ■£-$; after inflation, ^. H. D. Left, w. ff ; after infla- 
tion, w. ff. With the tuning-fork the aerial conduction is 
better than bone conduction in each ear; when placed on 
the central incisors with both ears closed, it is heard long- 
est in the left. With both ears open, is heard in the left by 
bone and aerial conduction; but is heard in the right by 
aerial conduction only; both ears show signs of a previous 
chronic otitis media, and there is some pharyngitis of the 
upper portion. I infer that there is middle-ear disease in 
both, and that there is labyrinthine or nervous trouble in 
the right, which seems to have dated from the time of the 
sunstroke. 



DEAFNESS FROM MUMPS. 395 



DEAFNESS FROM MENTAL AND NERVOUS EXHAUSTION. 

I have observed one case where deafness seemed to de- 
pend on mental and nervous exhaustion. A case may illus- 
trate it. A. F., a lawyer, aet. 44, consulted me for some 
difficulty in hearing. No constitutional dyscrasia. There 
was some difficulty in hearing the replies of witnesses in 
the court room. A moderate amount of tinnitus aurium 
accompanied the other symptoms. Inflation slightly im- 
proved the hearing. There was some catarrh of the Eusta- 
chian tubes. Bone conduction was weakened in both ears, 
and aerial conduction corresponded well to his hearing for 
^he voice. Not being able to otherwise account for his 
symptoms, I directed him to rest, improve his nutrition, ex- 
ercise in the open air, take all the sleep possible, besides 
avoiding mental worry. In four weeks I was gratified to 
find that the hearing had returned, the tinnitus had ceased, 
and bone conduction was restored. I make no attempt at 
explanation, but record what evidently was a fact. 



DEAFNESS FROM MUMPS. 

It may be proper to devote more space to this subject 
than is usual in text-books on the ear, as at the present time 
(1883) considerable interest seems to be taken in the sub- 
ject by otologists throughout the world. Whether the paro- 
titis is on one or both sides, only one ear is usually affected. 
The deafnes is generally, though not always, complete, 
even to the abolition of bone conduction. This occurs 
usually during the early period of the parotitis — from the 
first to the fifth day. Very aggravating tinnitus aurium, ver- 
tigo, unsteadiness of gait, nausea, vomiting, etc., are accom- 
panying symptoms. The vertigo frequently continues after 
most of the other symptoms have subsided, although it 
sometimes lasts but a few days, or it may be absent alto- 
gether. In a very large percentage of cases no signs of in- 
flammation about the meatus or tympanum exist, although 
catarrh of the pharynx is a frequent accompaniment of the 
disease. The Eustachian tubes are occasionally obstructed, 
together with signs of sunken drum membrane. A few 
cases show suppuration of the tympanum. Pain is only 
occasionally experienced, most cases reported showing a 



396 DISEASES OF THE EAR. 

singular absence of this symptom. A large percentage of 
the cases so far observed have been in adults, although 
children occasionally are rendered deaf from mumps. 

Perhaps the best method for arriving at a correct esti- 
mate of the nature of deafness from mumps is to revert to 
the experience of some of those who have observed the af- 
fection. Mr. Dalby(" Diseases and Injuries of the Ear," p. 
188) says: "On several occasions I have known partial 
deafness to take place during an attack of mumps, and in 
one instance total loss of hearing. The latter happened in 
a girl, set. 7; could hear perfectly w r ell before she had the 
mumps, but afterwards could not hear a sound. No history 
of hereditary syphilis." Toynbee, quoted by Turnbull, 
says: " The peculiar poison which causes the disease gen- 
erally known by the name of mumps is very often the 
source of complete deafness, which, however, usually occurs 
in one ear only. In these cases the nervous apparatus is 
evidently affected, as the deafness comes on suddenly, is 
usually complete, and, as a general rule, no appearance of 
disease can be detected in the meatus, membrana tympani, 
or tympanic cavity." He admits that a slight degree of 
hearing may sometimes remain. George P. Field, " Diseases 
of the Ear," Lond. 1882, says, p. 248, "Where it (nervous 
deafness) originates in (from ?) mumps, one side alone is 
usually implicated." He cites the case of a young man who, 
three months after a sharp attack of mumps, remained quite 
deaf, although no lesion of the membrana tympani could be 
detected. Dr. Knapp, in a discussion in the Trans. Internat. 
Med. Cong., 1881, Vol. III., p. 376, speaks of a case under his 
observation of a young lady who during an attack of mumps 
had become completely deaf in one ear without a trace of dis- 
ease of the outer or middle ear. Bone conduction was also 
destroyed. These cases were very rare in his practice, but 
he had frequently seen suppuration of the middle ear as 
a complication of mumps, but which did not differ in nature 
from the same disease elsewhere. Knapp also reports a 
case of one-sided deafness from mumps in the Archiv. 
Otol., vol. xi. p. 232. It was a young lady set. 15. She 
consulted him on May 25th, 1881. She had double 
parotitis. During this attack she noticed a diminu- 
tion in the hearing in the right ear, accompanied by 
tinnitus. The membranes were normal. The hearing 
of the right ear was soon completely lost, together with the 
bone conduction. The fellow ear was unaffected. He also 



DEAFNESS FROM MUMPS. 397 

reports another case on p. 385. Theresa O., set. 25, con- 
sulted him on Aug. 10th, 1882. The hearing was perfect 
previous to the attack of parotitis, and there had never 
been any disease of the ears. Six years since she had 
mumps on both sides. On the seventh day of the attack 
the hearing became lowered, and on the eighth day was 
completely lost. On the seventh, and on the following day 
there was excessive dizziness, which still exists to some 
degree. Bone and aerial conduction absent; middle ears 
healthy; patient does not remember whether tinnitus was 
present. 

Hinton, " The Questions of Aural Surgery" (Lond., 1874), 
p. 220, says: "Next or perhaps equal in frequency to 
scarlatina in this respect (the spoiling of the hearing) 
stands mumps, which has an effect on the nervous appa- 
ratus of the ear which has as yet received no explanation, 
and affords no clue to the use of remedies, every part of 
the ear being normal, so far as examination can extend, 
but the functions are almost abolished." He states, however, 
that some cases show clear signs of tympanic disorder 
mixed with the nervous symptoms. " The similarity of 
the nerve affection that follows mumps to that which en- 
sues upon parturition is very striking." I recently saw a 
case of total deafness at the Manhattan Eye and Ear Hos- 
pital, with the following history: Woman get. 20. In early 
childhood had had suppurative otitis media with very little 
impairment erf hearing. Seven years since she had an 
attack of mumps, during which she awoke from sleep one 
morning and found herself totally deaf. She has remained 
so ever since. Bone conduction entirely absent. The 
membranse are cicatricial, and the left one has a slight per- 
foration, and there is a little discharge. Her voice has the 
usual pitch of a person who has been deaf for a consider- 
able period. I have seen two other cases of mumps where 
the deafness came on suddenly and without explanation 
from the condition of the middle ear. Roosa, "Treatise on 
the Ear," fourth edition, p. 539, says: " Parotitis sometimes 
. . . leaves the patient profoundly deaf," which " may be 
from a direct extension of the inflammatory process from the 
gland into the auditory canal, tympanic cavity, and nerve, 
or we may suppose that a metastatic inflammation of the 
membranous labyrinth has occurred. I have seen but one 
case where it was plain that nerve deafness resulted from 
parotitis. In this case the loss of hearing occir*red with- 



398 DISEASES OF THE EAR. 

out pain, and affected both ears." He quotes a case from 
Dr. H. D. Noyes, where an adult had loss of hearing, accom- 
panied by inability to walk without staggering when his 
eyes were closed. 

This occurred and persisted after an attack of mumps. 
There was also metastatic orchitis on the same side as the 
deafness. Dr. Buck reports two cases in the Am. Jour. OtoL, 
July, 1881, and alludes to a third case he has seen, but the 
history of the last was imperfect. His first patient lost the 
hearing of the right ear completely on the fourth day of 
an attack of mumps. Bone conduction was also lost. In 
this case there were no symptoms of middle-ear trouble 
except an obstruction of the Eustachian tube and a slight 
sinking of the membrana tympani, some pharyngeal ca- 
tarrh, but the hearing was not improved by the subsidence 
of these symptoms. The second patient lost his hearing in 
one ear on the third or fourth day of an attack of mumps. No 
middle-ear trouble or any signs of disease sufficient to ac- 
count for the sudden loss of hearing; bone conduction abol- 
ished. These patients did not recover their hearing. He 
quotes Vogel from Ziemssen's Cyclopaedia of the Practice of 
Medicine, vol. vi. p. 838: " Not at all infrequently the laby- 
rinth and middle ear participate in the parotitis, in which case 
the pus probably passes directly by means of the vessels and 
nerves that go from the parotid gland to the ear. The ossi- 
cles of the ear thus become destroyed and, at the best, life- 
long deafness results." Vogel further remarks that the facial 
nerve seems especially adapted to conduct the inflammation 
into the auditory apparatus. Against this theory is the 
fact that the facial nerve is not often paralyzed in mumps 
as suggested by Burnett. 

In the Archiv. OtoL, Apr., 1882, is reported a case of 
mumps, with total deafness, by Moos, and translated by 
Spalding, as follows: W. S., aet. 13. On the previous Feb- 
ruary had double parotitis. Hearing was destroyed on the 
fifth day of the disease. Right membrana somewhat more 
opaque than usual; left more concave than right. Bone con- 
duction only in right ear by the tuning-fork C and C ; A' 
not heard. The author is inclined to favor the theory of 
metastasis. He concludes that the staggering gait and the 
profound deafness pointed to labyrinth disease. Brunner, 
translated by Ayers, in the Arch. Otol., June, 1882, reports a 
case of complete unilateral deafness from mumps as follows : 
A woman, aet. 30, had mumps on both sides. Soon after she 



DEAFNESS FROM MUMPS. 399 

became deaf in the right ear. This was accompanied by 
tinnitus and vertigo; bone conduction destroyed No 
signs of disease in the Eustachian tube or membrana tym- 
pani. Many discussions have been engaged in with a 
view of determining the mode in which the disease involves 
the ear. 

Dr. Roosa seems to conclude that the meatus or tympan- 
um, or both, become first inflamed, and that the internal ear 
suffers secondarily. Most of the reported cases have no 
tympanal complications, and those which do have, are so 
slight as not to cause serious deafness in the first place, and 
in the second are not of a sufficiently serious nature to 
travel as far as the labyrinth. The theory of passage by the 
facial nerve does not seem tenable, and we are left the old 
explanation of metastasis. It is true that the throat is often 
involved, and evidently as a consequence of the parotitis, 
but it does not produce serious ear complications, except 
perhaps the somewhat unusual condition of suppurative 
inflammation of the tympanum. Until a sufficient num- 
ber of autopsies are made, the labyrinthine condition can 
only be inferred from its disturbed function. It seems un- 
necessary to discuss the question as to whether the deafness 
depends on labyrinthine or nervous trouble. Its complete- 
ness, suddenness, the absence of middle-ear disease suffi- 
cient to cause it, and usually the presence of vertigo, nausea, 
unsteadiness of gait, etc., with complete abolition of bone 
conduction, point to the inner ear as the part affected. 

Treatment has had no influence, so far, in preventing the 
deafness or restoring the hearing after it has once been lost. 
In a few cases where there is pain from hyperemia, leeches 
and other similar measures may be employed. Iodide of 
potass, and mercury may be tried, but with very little hope 
of benefit. 

As electricity accomplishes so little in nervous or laby- 
rinthine affections dependent on other causes, it hardly can 
be expected to do so in this connection. It might, however, 
be tried. Middle-ear symptoms may be met according to 
general indications. 

DEAFNESS DEPENDENT ON GESTATION AND PARTURITION. 

This, in a large number of instances, seems to be asso- 
ciated with a state of anaemia of the labyrinth, often accom- 



400 DISEASES OF THE EAR. 

panied by nervous exhaustion or shock. If the exciting 
cause is not of too powerful a nature, and is not often re- 
peated, the hearing may completely recover. In numerous 
instances, however, the patient becomes harder of hearing 
at each accouchement, until she may be left in a condition 
of almost absolute deafness. Recently the following case 
came under my observation. Mrs. M., set. 25, has had chronic 
aural catarrh for six years. She has had four children, and 
after the birth of each child noticed that she was much harder 
of hearing. H. D. R. w. somewhat worse than left ; no 
signs of labyrinthine disease. The state of gestation may be 
accompanied by defective hearing from a similar cause. 
The patient may not take sufficient nourishment to sustain 
both the foetus and the mother, hence the anaemia. I have 
often seen this aural condition immediately benefited by 
the ingestion of large quantities of nourishing food, and 
perhaps the addition of alcoholic stimulants. Great fatigue 
or worry of mind in the pregnant woman will aggravate any 
existing ear symptoms. Wilde (Text-book, American edi- 
tion, p. 275) says " many females have become deaf imme- 
diately after parturition. In such cases I have generally 
observed a speckled opacity of the membrane." In the 
Trans. Am. Otol. Soc. for 1878, p. 180, Sexton states that 
Dr. Pierce, of Manchester, believes that the deafness of 
pregnancy begins with that condition. Mr. Lenox Brown 
regards such cases as common, and believes they are not 
catarrhal, but a thickening of the mucous membrane. 
" Sometimes they are nervous in character." Toynbee (Text 
Book, p. 368) thinks that a woman may become totally 
deaf from the nervous exhaustion attendant on childbed; 
in some instances of the latter, the deafness has begun with 
the birth of the first child, and increased with each succes- 
sive birth, until at last the nervous power was wholly lost. 
On p. 370 he reports a case as follows: " Mrs. B., aet. 40, 
pale, and of a nervous temperament, consulted me in 1850, on 
account of complete deafness in both ears. She stated that 
she had married in India ten years previously, and at the 
time of her marriage she could hear perfectly well. On the 
occasion of her first confinement, previous to which her 
hearing was still perfect, she suffered a good deal from ex- 
haustion, and this was followed by a great degree of deaf- 
ness, so that she could scarcely hear what was said to her, 
even when the voice was much raised. Upon getting up, 
and growing stronger, the deafness was so much relieved 



DEAFNESS IN TYPHUS AND TYPHOID FEVERS. 40 1 

that she merely required to be spoken to a little louder than 
usual. During each successive confinement, in India, 
amounting in all to four, the deafness greatly increased, 
and after each recovery became more permanent, until on 
the last occasion she remained as deaf as at present, when 
she is obliged to have recourse to signs. Indeed, she has 
never heard the voice of her younger children, and can only, 
by the movements of their lips, understand their words." 

A condition similar to this occurs with the vision; the 
optic nerve and retina sometimes undergoing complete 
atrophy, with resulting blindness. Little need be said about 
treatment; it will be readily suggested from the nature of 
things. Appropriate means may be used to maintain a 
proper nutritive condition and avoid, as far as may be, ex- 
cessive loss of blood at the confinement, and hasten the pa- 
tient's recovery. 



DISEASES OF THE EAR DEPENDENT ON TYPHUS AND TYPHOID 

FEVERS. 

These affections have usually been regarded as more or 
less labyrinthine in character, although, in the mention of 
the graver forms of otitis media in the exanthemata and 
the profound deafness which sometimes follows them, the 
ear diseases associated with typhus and typhoid fevers are 
included as belonging to a similar category. Most forms 
of otitis media and externa with pharyngeal and tubal 
catarrh and even mastoid complications, may exist as a 
consequence of these varieties of fever. Dr. Arthur Hart- 
man, Arch. Otol., vol. ix., No. 1, p. 55, translation by Knapp, 
says: " In almost all cases of typhus exanthematicus the 
general hyperemia of the head is accompanied by marked 
hyperemia and swelling of the naso-pharyngeal mucous 
membrane. It seems that a congestion of the auditory 
organ forms an essential part of the general congestion of 
the head. If it persists after the convalescence of the gen- 
eral disease, exudation may occur in different forms, either 
most pronounced in the drum cavity, or the tubes, or the 
labyrinth." Suppurative otitis media is not as likely to 
occur as a consequence of these fevers as in those of the 
exanthemata. It is true that labyrinthine complications may 
occur as a consequence of the extension of a severe middle- 
ear inflammation to the internal ear, but evidence does not 



402 DISEASES OF THE EAR. 

exist that the typhoidal patients are more liable to this 
accident than others. In some cases the patient becomes 
profoundly deaf without any middle-ear symptoms, as in 
a case reported by Toynbee, in " The Diseases of the Ear," 
English edition, p. 360, as follows: " Miss A. M. set 16, saw 
me on March 1st, 185 1. Eleven years previously she had 
an attack of typhus fever, and during the illness became so 
deaf as not to be able to hear the human voice. After the 
symptoms of fever had disappeared, the power of hearing 
slowly returned, until she was able to hear when loudly 
spoken to close to the head. There was no appearance of 
disease in either ear." Out of forty-two cases dependent 
on typhus, Hartman (1. c), observed three, in which "the 
hardness of hearing and the diminution of the bone-con- 
duction were so pronounced that a participation of the 
nervous apparatus in the disease had to be assumed. In 
one of these cases the objective examination showed no 
abnormity in the drum cavity; in the two others only 
slight alterations." He inferred that in the last-named 
cases there were inflammatory changes in the labyrinth — 
Burnette (" Treatise on the Ear") does not admit that there 
are labyrinthine complications in these affections, unless 
the tympanal symptons are neglected, when " a labyrinth 
disorder maybe established." Wilde, on " Diseases of the 
Ear" holds the opinion that the symptoms are mostly those 
of tympanal disease, but admits that there may be labyrinth- 
ine complications. What these are, seem, from lack of a 
sufficient number of autopsies, to be unknown. In none of the 
ear complications of typhus fever, is it assumed that any 
possible inflammation of the brain influences the aural 
symptoms. Hartmann (1. c.) observes that in three of his 
cases there was increase in the noises and hardness of hear- 
ing previously present, and that there was a recurrence of 
an otorrhcea in one case. In some instances an old otitis 
which was well-nigh cured had relapsed under the influence 
of the fever. The ear disease comes on during the febrile 
attack or soon after the patient has recovered. 

The prognosis is favorable. Most of the patients make a 
good recovery. Although, as previously hinted at, an occa- 
sional deaf mute may date his trouble to an otitis contracted 
during a typhoid or typhus fever. Little need be said concern- 
ing treatment. It may be done according to the exigencies of a 
given case ; the fact of its febrile causation need not modify 
treatment. 



INSTRUMENTS FOR AIDING THE HEARING. 403 



INSTRUMENTS FOR AIDING THE HEARING. 

By these, I refer to the different forms of hearing-trum- 
pets, the audiphone, etc. The action of the hearing- 
trumpet is simply to collect and convey to the membrana 
tympani a larger number of sonorous undulations than 
would otherwise reach it. The undulations pass through 
the middle-ear mechanism precisely as in normal unaided 
hearing, with sometimes, as hereafter will appear, a certain 
amount of aid from bone conduction. In the construction of 
the trumpet there is no difficulty, at least at the near point, 
in collecting as many sound-waves as are desired; the pro- 
blem is, rather, to collect undulations that are likely to reach 
the cochlea properly analyzed — that is, to be appreciated as 
articulate sounds, proper tones and pitch in music, etc. The 
difficulty with most ear-trumpets is that there is likely to 
be a constant roaring, like a sea-shell, when the trumpet is 
applied to the ear, and all loud sounds are so exaggerated 
as to be both indistinct and painful, especially as there is 
frequently a certain amount of hyperesthesia of the audi- 
tory nerve in such cases. Tinnitus may also result, and in 
some cases, congestion of the tympanum from the concus- 
sion of the strong undulations. 

To obviate this, many expedients have been resorted to, 
such as avoiding the use of metal in the construction of the 
trumpet, and substituting some less resonant material; 
covering the mouth of the trumpet with a piece of metal 
in which are placed larger or smaller openings as suggested 
by Dr. C J. B. Williams, even down to the size of those used 
in the wire sieve, of the North trumpet, and the use of reflec- 
tors, vibrators, etc., in the interior of the trumpet. Perhaps 
the most successful procedure of all these for diminishing 
this reverberation is the screen or sieve placed over the 
mouth of the trumpet, which is a most important feature of 
many instruments. Specific conditions of the ear have by 
many authors been regarded as a cause for selecting par- 
ticular appliances for aiding the hearing. I am not certain 
that any person having a small amount of hearing remain- 
ing may not have this augmented by the use of an ear- 
trumpet, whether the defect is caused by labyrinthine trou- 
ble, thickened and adherent drum membrane, or perforation 
and even loss of one or more of the ossicula — it being 
simply a matter of collecting and conveying to the cochlea 



404 



DISEASES OF THE EAR. 



a larger number of undulations than would otherwise reach 
the nerve. The different forms of trumpet may be made of 
Japanned tin, horn, vulcanite, German silver, ebonite, etc. 
If the deafness is not profound, the ordinary conversation- 




Fig. 95.— Conversation Tube. 

tube, Fig. 95, may be used, as it is quite inconspicuous and 
easy to carry; moreover, by its flexible tube it enables the 
bowl to be placed near to the speaker's mouth, whereby 
much increase in the power and distinctness of the articu- 




Fig. 96.— The Dipper Trumpet. 

lation is gained. Deaf patients are constantly disappointed 
at the very moderate gain to the hearing resulting from an 
attempt to hear a lecture or a concert. 

The tip for the insertion of the trumpet into the meatus 




Fig. 97.— Ordinary Japanned Tin Trumpet. 

should be gently pushed in, as in the event of its being 
crowded in too far it interferes with the best hearing; be- 
sides it irritates the canal and may produce unpleasant 
congestion of the tympanum. For listening to any distant 
sound a larger expansion of the trumpet-shaped extremity 



EAR TRUMPETS. 



405 



needs to be made like the one in Fig. 96 or Fig. 97, 
which are very similar to the famous Martineau trumpet. 
None of the smaller, so-called invisible, aids to hearing are 
of any use whatever. I have latterly come to the con- 
clusion that the North earphone, Fig. 98, is the most 
useful of any hearing-trumpet I am acquainted with. It 
is made of four sizes, the illustration being somewhat 
less than half the diameter of the largest size. It may be 
used as in No. 1, with the short tip inserted into the meatus. 
It will be seen that a rubber tube is drawn over it, so as 
to cause it to adjust better to the ear. When in posi- 




Fig. 98.— North's Earphone. 



tion the bowl rests against the temple, thus aiding the hear- 
ing by bone conduction. In other instances it will be more 
convenient to use No. 2 with the flexible tube attached, al- 
though in this instance no aid is obtained from bone con- 
duction. On the top of No. 2 may be seen one of the coarse 
wire meshes which the inventor calls a " refiner." Three of 
these are used, each of a different-sized mesh; the smallest is 
extremely fine. The object of these is to soften or tone 
down the overpowering reverberations, rendering articulate 
sounds much more distinct. It is somewhat a matter of 
experiment what exact combination of these refiners is to be 
made; in some cases, where the hearing is not too much 
lowered and there is great sensitiveness to strong vibrations, 



406 DISEASES OF THE EAR. 

all three of the refiners may be used. In other instances 
only the coarsest-meshed refiner is used. The same observa- 
tion may be made, to a certain degree, in reference to the 
selection of the particular-sized instrument to be used. It 
will be seen that the patient may " try" each size with all the 
combinations of refiners, until one is found best adapted 
to the given case. The instrument admits of quite a large 
number of combinations. I have been unable to study the 
interior of the earphone, but it is described by the inventor 
as having a series of tubings, refiners, drumheads, and 
detonating wires : the latter being forked and running 
from the bottom where it is attached to the reflector, seen 
on the depressed portion, through the full depth of the in- 
strument. I am indebted to D. M. Coe, 295 4th Ave., the 
agent, for the description and woodcuts. I came to a 
knowledge of its value from the experience of some of my 
patients, who had used it with greater satisfaction than 
other instruments which they had tried. [I have recently found 
that patients do not seem to be more benefited by this instru- 
ment than by many others.] 

RHODES' AUDIPHONE OR OSTEOPHONE (THOMAS). 

This is illustrated in Fig. 93, as it is applied by its 
extremity to the incisor teeth of the upper jaw. In Fig. 
94 is seen the mode in which the proper tension is accom- 
plished by means of cords. It is composed of vulcanite, 
and is twenty-five to thirty cm. long, and twenty to twenty- 
five cm. broad. The convex surface catches the vibrations, 
which are carried through the teeth and bones of the face 
and cranium, to the acoustic nerve, acting purely by bone 
conduction. The inventor of this instrument at one time 
visited the Manhattan Eye and Ear Hospital to exhibit 
it. Various experiments were made, which were alto- 
gether negative in result. I remember that I applied it 
to my upper teeth with both ears tightly closed. I could 
hear conversation at about three feet without any aid, and 
it was impossible to increase this distance by the use of the 
audiphone; neither did sounds appear louder or more dis- 
tinct, nor could any increase of sonorous undulations be 
perceived. My opinion of its utility was unfavorable. 
Since that time I have tried it in many cases, and have not 
been able to produce a sufficient amount of improvement to 
the hearing to justify a continuance of its use. Since that 
time I have heard that Dr. Agnew found a patient who 



THE OSTEOPHONE. 



407 



could hear preaching at about twenty feet with the audi- 
phone when not a word could be distinguished without it. 




Fig. 3. The Audiphone 
properly adjusted to the 
upper teeth ; ready ior 
use. (Side view.) 

Fig. 99. 

Dr. Carmalt of New Haven, Conn., reports a somewhat 
similar case. Dr. Knapp, Arch. Otol., Vol. IX., No. 1, p. 




Fig. 2. The Audiphone 
in tension ; the proper 
position for hearing. 

Fig. 100. 

89, sums up the results of the use of the audiphone in four- 
teen cases, comparing the instrument with the most ap- 
proved form of ear trumpet. With the audiphone there 
26 



408 DISEASES OF THE EAR. 

was no increase in the hearing in twenty per cent, of the 
cases, a slight increase in twenty per cent, and a moderate 
increase in sixty per cent; whereas the ear trumpet in- 
creased the acuteness of hearing in all cases, slight in eight 
per cent, moderate in thirty-five per cent, and great in 
fifty-eight per cent, so it is readily inferred that the ear trum- 
pet is greatly superior to the audiphone as an aid to hear- 
ing. The Japanese fan, made of quite stiff material, is 
sometimes superior to the Rhodes audiphone. It requires 
no adjustment, the patient is not suspected of carrying any 
aid to hearing, and it costs only a few cents, whereas the 
audiphone costs from ten to twenty dollars, or more. 

As hopelessly deaf people are anxious to try anything 
that affords a chance of relief, and as the fan and audiphone 
do sometimes benefit, they may be recommended. 



INDEX. 



Abscesses of the lobule, 75 

Acute catarrhal inflammation of the 

middle ear, 136 
Adenoid growths, removal of, 216 
Agnew's method of using the Eusta- 
chian catheter, 204 
Apparatus for generating steam, 153 
Artificial drum membrane, 275 
Aspergillus nigricans in the external 

ear, 115 
Aspergillus, diagnosis of, 118 
Aspergillus, treatme "it of, 1 19, 122 
Audiphone or osteophone, 406 
Audiphone, woodcut of, 407 
Aural catarrh, chronic, treatment of, 

18 
Aural catarrh, chronic, prognosis of, 

183 
Aural catarrh, chronic, pathology of, 

179 

Auricle, description of normal, 45 
Auricle, erysipelas of, 51 
Auricle, eczema of, 46 
Auricle, fibrous tumors of, 53 
Auricle, hematoma of, 56 
Auricle, horny growths of, 52 
Auricle, herpes of, 49 
Auricle, malformations of, 76 
Auricle, intertrigo of, 52 
Auricle, perichondritis of, 59 
Auricle, injuries of, 73 
Auricle, pathogenesis of perichon- 
dritis of, 67 



Bezold, on a peculiar form of mas- 
toid cell disease, 287 
Bellocq's cannula, 217 
Bivalve speculum, Roth's, 135 
Blake's polypus snare, 264 
Bone, carious and necrotic from a 



case of mastoid disease, wood cut, 
294 

Boiler makers' and ship calkers' deaf- 
ness, 355 

Brain, diseases of causing labyrin- 
thine or acoustic nerve disease, 369 

Buttle's inhaler, Pomeroy's modifica- 
tion of, 235 



Calcific and other spots on the 
membrane in chronic aural catarrh, 
168 

Cannula, Bellocq's, 217 

Cannula scissors, Dr. A. H. Smith's, 
214 

Catheter holder, Pomeroy's. 154 

Catarrh of the tympanum, treatment 
of acute form, 147 

Catheter, Pomeroy's faucial Eusta- 
chian, 23 

Catarrhal inflammation of the tym- 
panum, chronic, 157 

Catarrhal inflammation of the middle 
ear, acute, 136 

Catheter, the Eustachian, 24 

Cells, inflammation of mastoid, 2S4 

Cerumen, impacted. 86 

Cerumen, impacted, mode of re- 
moval of, 94 

Cerebrospinal meningitis, its effect 
on the hearing, 373 



Dampness, its prejudicial effect on 
ear diseases, 338 

Davidson's spray instrument, 155 

Deafness, boiler makers' and ship 
calkers', 355 

Deafness from gestation and partu- 
rition, 399 



4io 



INDEX. 



Deafness from sunstroke, 394 
Deafness from sclerosis of the pos- 
terior columns of the cord, 393 
Deafness, one sided, detection of, 

39 
Deformed auricles, operations for, 

7 8 
Desquamative inflammation of 

meatus externus, 98 
Diagnosis of diffuse inflammation of 

the meatus, Hi 
Diagnosis, the tuning fork in, 32 
Diffuse inflammation of the meatus 

externus, diagnosis of, ill 
Diffuse inflammation of the meatus. 

107 
Diplacusis Binauricularis, 368 
Diplacusis, 367 
Diplacusis monauricularis, case of, 

367 

Diagnostic tube, Toynbee's, 175 

Diseases of the ear dependent on 
typhus and typhoid fevers, 401 

Double hearing, 367 

Drills, Buck's, for opening into mas- 
toid cells, 297 

Drainage, effects of defective on the 
ear, 333 



Ear, malignant disease in and about 

the, 316 
Ear mirrors, 17-18 
Ear, mode of examining, 23 
Ear specula, 19-22 
Earphone, the, 405 
Eczema of auricle, 46 
Eczema of auricle, tieatment of, 47 
Eustachian catheter, the, 24 
Eustachian tube, auscultation of, 175 
Eustachian tube, appearances on 

rhinoscopy, 173 
Eustachian tube Hackley's spray in- 
strument for treating, 205 
Eustachian tube, management of in 

chronic aural catarrh, 200 
Eustachian tube, rhinoscopy of, 172 
Erysipelas of the auricle, 51 
Examination, of the ear, mode of, 23 
Excision of the uvula, mode of, 

220 
Exostosis of meatus, treatment of, 
126 



I Exhaustion, deafness from, 395 
I Exostosis of the meatus, 123 



Fan, the Japanese, 408 

Faucial catheter, mode of using, 203 

Faucial Eustachian catheter, Pome- 

roy's, 23 
Fibrous tumors of the auricle, 53 
Fluid in tympanum in chronic aural 

catarrh evacuated by puncture, 191 
Forceps, Hinton's polypus, 267 
Forceps, Xoyes' polyp, 267 
Forceps, Pomeroy's polyp, 268 
Forceps, Toynbee's, modified by Dr. 

Bumstead, 267 
Foreign bodies in the meatus and 

tympanum, 80 
Forehead mirrors, 17-18 
Frsenkel's speculum, 136 
Furuncle of meatus, treatment of, 

103 
Furuncle of the meatus, 100 



Gal vano caustic apparatus Schroet- 

ter's, 219 
Gestation, and parturition, deafness 

from, 399 
Goodwillie's speculum, 136 
Gruber's, Green's and Hartman's 

tenotomes, 198 
Gruber's paracentesis knife, 150 
Growths, adenoid, removal of, 216 



HEMATOMA of auricle, 56 
Hackley, spray instrument for the 

Eustachian tube. 205 
Hearing, instruments for aiding, 

403 
Hearing, modes of testing, 37 
Herpes of the auricle, treatment of, 

50 
Herpes zoster auricularis, 49 
Hinton, polypus forceps of, 267 
Horny growths of the auricle, 52 
Hyperostosis of meatus, 123 



Impacted cerumen, 86 
Injuries of the auricle, 73 
Intertrigo of the auricle, 52 



INDEX. 



411 



Inflammation of the meatus, circum- 
scribed form, 100 

Injuries, effects of on the tympanum 
and labyrinth, 385 



Jarvis's wire snare ecraseur, 216 
Japanese fan, the, 408 



Labyrinth and tympanum, results 
of injuries on, 385 

Labyrinth, primary acute inflamma- 
tion of, 390 

Labyrinth, diseases of affected by 
syphilis, 338 

Labyrinth, diseases of dependent on 
affections of the brain or its mem- 
branes, 369 

Labyrinthine disease from cerebro- 
spinal meningitis, 373 

Labyrinthine disease dependent on 
middle ear disease, 357 

Lobulus, abscesses of, 75 



Malaria, effects of, on the ear, 333 
Malformations of the auricle, 76 
Malignant disease of the ear, cases 

of, 325 
Malignant disease in and about the 

ear, 316 
Malignant disease of the ear, wood 

cut showing, 320 
Mastoid cells, Buck's drills for 

opening into, 297 
Mastoid cell disease, symptoms of, 

287 
Mastoid cell disease, treatment of, 

290 
Mastoid cells, inflammation of, 284 
Mastoid cells, modes of operating 

on, 295 
Mastoid cells, primary inflammation 

of, 282 
Mas'oid, periostitis of outer surface, 

278 
Mastoid periostitis, treatment of, 

279 
Mathieu's tonsillotome, 221 
McKenzie's condenser, 134 
McKenzie's modification of Physick's 

tonsillotome, 221 



Meatus, circumscribed inflammation 
of, 100 

Meatus, diffuse inflammation of, 107 

Meatus, exostosis and hyperostosis 
of, 123 

Meatus externus, desquamative in- 
flammation of, 98 

Meatus, furuncle of, 100 

Membrane, appearances of in chron- 
ic aural catarrh, 167 

Membrane, artificial drum, 275 

Membrana, collapse of causing pain, 

139 

Membrana, tumors of, cases, 350 

Membrana tympani, calcific changes 
in otitis chronica, 169 

Membrana tympani, directions for 
puncturing, 149 

Meatus and tympanum, foreign bod- 
ies in, 80 

Meniere's disease, 377 

Meniere's disease, cases of, 383, 

384 
Meniere's disease, treatment of, 

383 

Method of using the faucial Eus- 
tachian catheter, 203 

Microscopic appearances of a myxo- 
sarcoma of the ear. 323, 324 

Middle ear disease as affecting the 
labyrinth, 357 

Middle ear, acute catarrhal inflam- 
mation of, 136 

Middle ear and labyrinth, diseases 
of influenced by syphilis, 328 

Mirrors, ear, 17, 18 

Mode of removing impacted ceru- 
men, 94 

Mumps, deafness from, 395 

Myringomycosis aspergillina, 115 



Nasal cavity, cut showing, 172 

Naso-pharyngeal catarrh, manage- 
ment of in chronic otitis, 209 

Nares, the appearance of in chronic 
aural catarrh, 1 71 

Neuro-paralytic form of perichondri- 
tis of the auricle, 63 

Nervous exhaustion, deafness from, 
395 

Newman's spray producer, 211 

Noyes, polypus forceps of, 267 



412 



INDEX. 



One sided deafness, detection of, 39 
Operations on the mastoid, Schwartze, 

301 
Operations, for deformed auricles, 

78 
Othematoma, of the auricle, 56 
Otoscope, Siegle's, 229 
Otitis media chronica, treatment of, 

188 . 
Otitis media purulenta chronica, 239 



Parotitis, deafness from, 395 
Papulo-tubercular affection of the 
membrana, in hereditary syphilis, 
cases of, 350 
Paracusis, duplicata, (Moos), 367 
Pain in the ear from diseased throat, 

164 
Pain in the ear from collapsed mem- 
brana, 139 
Paracentesis of membrane in chronic 
aural catarrh for evacuation of 
fluid, 191 
Paracentesis knife, Gruber's, 150 
Paracentesis of membrane in chronic 

aural catarrh, 197 
Perichondritis, neuro-paralytic form 

of, 68 
Perforation of the membrana, diag- 
nosis of, 244 
Perichondritis of auricle, 59 
Periostitis, of outer surface of mas- 
toid, 278 
Politzer's operation, Pomeroy's ap- 
paratus for perf orming, wood cut, 
248 
Polypus scissors, Gruber's, 268 
Polypi, wood cut, showing 'from 

Wilde, 261 
Polypi, aural, 260 
Polypi, aural, treatment of, 264 
Polypus forceps, Pomeroy's, 268 
Polypus, microscopical appearance 

of, 262 
Polypus curette. Buck's, 268 
Pomeroy's modification of Buttle's 

inhaler, 235 
Pomeroy's post nasal syringe, 151 
Pomeroy's hard rubber spray instru- 
ment, directions for usmg, 223 
Pomeroy's hard rubber spray instru- 
ment, 203 



Post nasal syringe, Pomeroy's, 151 

Powder blower, Dr. A. H. Smith's, 
213 

Prophylaxis, in acute aural catarrh, 
155 

Prudden, on microscopical appear- 
ances of a polypus, 262 

Puncture of membrane in chronic 
aural catarrh, 197 

Puncturing the membrana, directions 
for, 149 

Purulent inflammation of the tym- 
panum, chronic, 239 

Purulent inflammation of the middle 
ear, treatment of, 232 

Purulent inflammation of the tym- 
panum, acute, 226 

Purulent inflammation of the middle 
ear, chronic, treatment of, 247 



Quinine, effects of on the ear, 331 



Rhinoscopic image of Eustachian 

tube, etc., wood cut, 173 
Rhinoscopy of the Eustachian tube, 

172 
Roth's bivalve speculum, 135 



Sass's spray instrument, etc., 212 
Schroetter's galvano-caustic appara- 
tus, 219 
Schwartze's cases of mastoid disease, 

301 
Sclerosis of the posterior columns of 

the cord, deafness from, 393 
Siegle's instrument in chronic aural 

catarrh, 196 
Sie'gle's otoscope, 220 
Smith's cannula scissors, 214 
Smith's powder blower, 213 
Snare, Plake's polypus, 264 
Snare, Jarvis', 216 
Spatula, tongue, 131-133 
Specula, ear, 19-22 
Speculum, Goodwillie's, 136 
Speculum, Fraenkel's, 136 
Speculum, Zaufal's, wood cut, 173 
Spray instrument. Davidson's, 155 
Spray producer, Newman's, 21 1 



INDEX. 



413 



Spray instrument, Sass's, with com- 
pressed air apparatus, 212 

Spray instrument, Pomeroy's, of 
hard rubber, 203 

Steam, apparatus for generating, 

153 

Sunstroke, deafness from, 394 
Suppurative otitis, considerations on 

fatal cases of, 307 
Syphilis, hereditary, deafness depen- 
dent on, 347 
Syphilitic inflammation of the mid- 
dle ear, labyrinth, etc., 338 
Syringe, Warner's post nasal, 200 
Syringe for the ear, Pomeroy's flange 
instrument, 95 



Tabes dorsalis, deafness from, 
393 

Tenotomes, Green's, Hartman's, 
and Gruber's, 198 

Tensor tympani, mode of dividing, 
199 

Tests for the hearing, 37 

Tuning fork , in diagnosis, 32 

Tinnitus aurium in chronic aural 
catarrh, 187 

Tongue spatulae, 131 — T33 

Tonsils, management of by opera- 
tion or otherwise, 220 

Tonsillotome, Mathieu's, 221 

Tonsillotome, McKenzie's modifica- 
tion of Physick's, 221 



Toynbee's artificial drum membrane, 
wood cut, 275 

Traumatism, effects of on the tym- 
panum and labyrinth, 385 

Treatment of exostosis and hyperos- 
tosis, 126 

Treatment of furuncle of the meatus 
103 

Trumpets, hearing, 404 

Tympanum, chronic catarrhal in- 
flammation of, 157 

Tympanum, acute purulent inflam- 
tion of, 226 

Tympanum, collections in, wood cut 
showing, 164 

Toynbee's diagnostic tube, 175 

Typhus and typhoid fever, diseases 
of the ear dependent on, 401 . 



Uvula, mode of removing, 220 



Van Allen, Dr. , case of tumor of 

membrana, 354 
Vault of pharynx, wood cut, 174 
Voltolini, on primary acute inflam- 
mation of the labyrinth, 390 



Warner's post nasal syringe, 200 
Zaufal's speculum, wood cut, 173 



THE END 



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